Clinical Practice Guideline Update Research Articles

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity.

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Case Study: Management of Anterior Cruciate Ligament Injuries.

Considering the frequency of anterior cruciate ligament (ACL) tears, optimal management of these injuries was the subject of a 2022 clinical practice guideline update from The American Academy of Orthopaedic Surgeons (AAOS) with input from representatives from the American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Orthopaedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American College of Emergency Physicians. The eight recommendations and seven options to guide orthopaedic surgeons and other physicians managing patients with these anterior cruciate ligament injuries are based on the best current available evidence. The cases presented in this article are examples designed to demonstrate the clinical application of these guidelines.

Rationale and design of a cardiac safety study for reduced cardiotoxicity surveillance during HER2-targeted therapy

BackgroundEchocardiograms are recommended every 3 months in patients receiving human epidermal growth factor 2 (HER2)-targeted therapy for surveillance of left ventricular ejection fraction (LVEF). Efforts to tailor treatment for HER2-positive breast cancer have led to greater use of non-anthracycline regimens that are associated with lower cardiotoxicity risk, raising into question the need for frequent cardiotoxicity surveillance for these patients. This study seeks to evaluate whether less frequent cardiotoxicity surveillance (every 6 months) is safe for patients receiving a non-anthracycline HER2-targeted treatment regimen.Methods/designWe will enroll 190 women with histologically confirmed HER2-positive breast cancer scheduled to receive a non-anthracycline HER2-targeted treatment regimen for a minimum of 12 months. All participants will undergo echocardiograms before and 6-, 12-, and 18-months after initiation of HER2-targeted treatment. The primary composite outcome is symptomatic heart failure (New York Heart Association class III or IV) or death from cardiovascular causes. Secondary outcomes include: 1) echocardiographic indices of left ventricular systolic function; 2) incidence of cardiotoxicity, defined by a ≥ 10% absolute reduction in left ventricular ejection fraction (LVEF) from baseline to < 53%; and 3) incidence of early interruption of HER2-targeted therapy.ConclusionsTo our knowledge, this will be the first prospective study of a risk-based approach to cardiotoxicity surveillance. We expect findings from this study will inform the development of updated clinical practice guidelines to improve cardiotoxicity surveillance practices during HER2-positive breast cancer treatment.Trial registrationThe trial was registered in the ClinicalTrials.gov registry (identifier NCT03983382) on June 12, 2019.

Adjuvant ipilimumab and nivolumab in renal cell carcinoma: more questions than answers

Immune checkpoint inhibitors, such as pembrolizumab (a PD-1 inhibitor), nivolumab (a PD-1 inhibitor), and ipilimumab (a CTLA-4 inhibitor), are widely used in patients with clear cell renal cell carcinoma. 1 Powles T Albiges L Bex A et al. ESMO Clinical Practice Guideline update on the use of immunotherapy in early stage and advanced renal cell carcinoma. Ann Oncol. 2021; 32: 1511-1519 Summary Full Text Full Text PDF PubMed Google Scholar Single-agent PD-1 inhibitors, such as pembrolizumab or nivolumab, have activity in advanced disease. 2 Motzer RJ Escudier B McDermott DF et al. Nivolumab versus everolimus in advanced renal-cell carcinoma. N Engl J Med. 2015; 373: 1803-1813 Crossref PubMed Scopus (4094) Google Scholar , 3 McDermott DF Lee JL Bjarnason GA et al. Open-label, single-arm phase II study of pembrolizumab monotherapy as first-line therapy in patients with advanced clear cell renal cell carcinoma. J Clin Oncol. 2021; 39: 1020-1028 Crossref PubMed Scopus (89) Google Scholar Adjuvant pembrolizumab significantly improved disease-free survival after nephrectomy for patients with high-risk renal cell carcinoma in the KEYNOTE-564 study, and also produced an immature trend towards better overall survival. 4 Choueiri TK Tomczak P Park SH et al. Adjuvant pembrolizumab after nephrectomy in renal-cell carcinoma. N Engl J Med. 2021; 385: 683-694 Crossref PubMed Google Scholar Adjuvant nivolumab plus ipilimumab versus placebo for localised renal cell carcinoma after nephrectomy (CheckMate 914): a double-blind, randomised, phase 3 trialAdjuvant therapy with nivolumab plus ipilimumab did not improve disease-free survival versus placebo in patients with localised renal cell carcinoma at high risk of recurrence after nephrectomy. Our study results do not support this regimen for the adjuvant treatment of renal cell carcinoma. Full-Text PDF

Assessment of Middle Ear Function Using Wideband Acoustic Immittance: Current Practices and Future Prospects.

Acoustic immittance tests have been used in clinical practice for the assessment of middle ear function since the 1960s. In the following decades, single-frequency admittance tympanometry has become a staple test of middle ear function in routine audiological practice, and to a lesser extent, multifrequency tympanometry. The acoustic properties of middle ear are best understood through physiological assays of its gain spectrum, tested over a wide range of frequencies; i.e., the middle ear transfer function. Yet, clinical assessment with multi-frequency tympanometry has been limited to frequencies below 2000 Hz. Thanks to advances in probe characterization techniques, measurements of impedance at frequencies beyond 2,000 Hz have become possible. These advances ushered in a new frontier for acoustic immittance research and paved the way for a host of new wideband acoustic immittance (WAI) measures that promised improved clinical assessments through better approximation of the transfer function and acoustic mechanics of the middle ear. Translational and clinical research further developed and refined WAI for clinical use through establishment of clinical norms, emergence of data in ears with conductive disorders, and demonstrated improvements in test accuracy of WAI over single-frequency tympanometry for a variety of clinical populations. Together with emergence of commercially available systems, since the mid-2000s, these developments signal the emergence of WAI testing as a standard audiological tool for the assessment of the middle-ear function. Although clinical adoption of this promising diagnostic technology is lagging, widespread adoption is expected with further refinement of WAI measures, and as updated clinical practice guidelines recommend the incorporation of WAI testing into clinical test batteries (e.g., JCIH, 2019).[1]

321 Cancer risk with topical pimecrolimus and tacrolimus for atopic dermatitis: systematic review and Bayesian meta-analysis

Abstract Atopic dermatitis affects millions worldwide and is effectively managed by topical treatments, including topical calcineurin inhibitors, pimecrolimus and tacrolimus. In 2005 and 2011, the FDA released reviews associating topical calcineurin inhibitors with a theoretical cancer risk, albeit an uncertain association. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors. We systematically identified randomized controlled trials, comparative, and non-comparative non-randomized studies from database inception to 6 June 2022, from MEDLINE, EMBASE, GREAT, LILACS, ICTRP, FDA, EMA, company registers and relevant citations. We included studies in any language addressing the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors for greater than 3 weeks. We excluded split-body studies. We conducted a Bayesian meta-analysis and used the GRADE approach to determine the certainty of the evidence. A multidisciplinary panel including patients, advocacy groups and care providers, set an a priori threshold of 1 in 1000 risk difference as a clinically important effect. We analysed 121 studies (52 randomized controlled trials and 69 non-randomized studies) including 3.4 million patents followed for a mean of 11 months (range: 0.7–120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was neither different from controls (absolute risk 4.70 per 1000 with topical calcineurin inhibitor exposure vs. 4.56 per 1000 without; odds ratio 1.03 [95% credible interval 0.94–1.11], moderate-certainty evidence) nor the general US population (4.6 per 1000). Findings were similar in infants, children, and adults, and were robust to trial sequential, subgroup and sensitivity analyses. Among infants, children and adults with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the management of patients with atopic dermatitis. Our findings provide actional information to inform updated clinical practice guidelines, product labels and continuing education for care providers, to clarify the safe usage of topical calcineurin inhibitors.

Clinical Practice Guidelines for the Immunological Management of Chromosome 22q11.2 Deletion Syndrome and Other Defects in Thymic Development

Current practices vary widely regarding the immunological work-up and management of patients affected with defects in thymic development (DTD), which include chromosome 22q11.2 microdeletion syndrome (22q11.2del) and other causes of DiGeorge syndrome (DGS) and coloboma, heart defect, atresia choanae, retardation of growth and development, genital hypoplasia, ear anomalies/deafness (CHARGE) syndrome. Practice variations affect the initial and subsequent assessment of immune function, the terminology used to describe the condition and immune status, the accepted criteria for recommending live vaccines, and how often follow-up is needed based on the degree of immune compromise. The lack of consensus and widely varying practices highlight the need to establish updated immunological clinical practice guidelines. These guideline recommendations provide a comprehensive review for immunologists and other clinicians who manage immune aspects of this group of disorders.

Prevalence of Hypertension among Children Based on the New American Academy of Pediatrics Clinical Practice Guidelines.

In 2017, the American Academy of Pediatrics (AAP) updated clinical practice guidelines for the diagnosis and management of hypertension in children. The present study aimed to assess the prevalence of hypertension in Iranian children based on the latest guidelines. Data on 7301 student participants (3589 boys and 3712 girls) aged between 7-12 yr were assessed. The data were extracted from the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable Disease (CASPIAN V) school-based study conducted in the 30 provinces of Iran in 2015. Blood pressure (BP) was classified as normal, elevated BP, and stage 1 and 2 hypertension using weighted analysis and the 2017 AAP guidelines. All analyses were performed in STATA 14.0 statistical software, with findings presented in terms of prevalence. The overall prevalence of high BP in Iranian children was 14.7%. In addition, 15.1% of boys had high BP, with 9.4% and 1.7% of them with stage 1 and 2 hypertension, respectively. Moreover, 14.3% of girls had high BP, of which 10% had stage 1 and 1.3% with stage 2 hypertension. For elevated hypertension, it was observed in 4% of boys and 3% of girls. Using the 2017 AAP guidelines demonstrated a higher prevalence of hypertension in children (14.7%) in Iran. The prevalence of hypertension in boys was slightly higher compared to girls.

Adapted Evidence-Based Clinical Practice Guidelines for Diagnosis and Treatment of Epilepsies in Children: A Tertiary Children's Hospital Update

Hypothesis and/or BackgroundWe recently updated and merged the adapted clinical practice guidelines (CPGs) for the diagnosis and treatment of children with epilepsy of a tertiary-level hospital. Medical knowledge is always evolving. As a result, it is critical to revisit the clinical standards on a frequent basis to ensure that the best services are offered to the target receivers. The purpose of this article was to update and merge the CPGs at Alexandria University Children Hospital (AUCH) for the diagnosis (2014) and treatment (2016) of children with epilepsy to unify and standardize the practice for better care and outcome. MethodsThis review and update CPG project was initiated by assembling a Guideline Review Group (GRG). The GRG conducted focus group discussions and decided to search any published updates of the recommendations of the previously identified high-quality and evidence-based CPG developed by the SIGN (Scottish Intercollegiate Guidelines Network) and to merge the two previous local CPGs under one comprehensive CPG for full management of epilepsy in children. The high quality of the selected source CPG from SIGN was based on quality assessment of CPGs undertaken previously using the Appraisal of Guidelines for Research and Evaluation II Instrument. The GRG followed the Checklist for the Reporting of Updated Guidelines (CheckUp), which is the CPG tool recommended by the Enhancing the Quality and Transparency of health Research Network for reporting of updated CPGs in addition to the RIGHT-Ad@pt Checklist for Adapted CPGs. The finalized updated CPG draft was sent to the external reviewer group topic experts. ResultsThe group updated 10 main categories of recommendations from one source CPG (SIGN). The recommendations included (1) epilepsy diagnosis; (2) recognition, identification, and referral; (3) pharmacological treatment of epilepsy and epilepsy syndromes; (4) nonpharmacological treatment of epilepsy and epilepsy syndromes; (5) managing pharmacoresistant epilepsy; (6) management of epilepsy in special groups; (7) medications; (8) children and caregiver education and support; (9) comorbidities and mortality; and (10) transitional care from pediatric to adult care services. ConclusionsThe finalized CPG provides evidence-based guidance to health care providers in AUCH for the diagnosis and management of epilepsy in children. The study also established the significance of a collaborative clinical and methodological expert group for the update of CPGs, as well as the usability of the “CheckUp” and “RIGHT-Ad@pt” CPG Tools.

P112: Updated clinical practice guidelines for managing children and adults with 22q11.2 deletion syndrome*

P112: Updated clinical practice guidelines for managing children and adults with 22q11.2 deletion syndrome*

397. Oral Vancomycin Versus Fidaxomicin for Clostridiodes difficile: A Comparative Retrospective Evaluation across a Large, Multi-center Healthcare System

Abstract Background The Infectious Diseases Society of America and Society for Healthcare Epidemiology of America recently published the 2021 Focused Clinical Practice Guideline Update on Management of Clostridioides difficile in Adults that recommends fidaxomicin as a preferred treatment for initial and recurrent C. difficile infection (CDI) over oral vancomycin. The aim of this study was to evaluate clinical outcomes of adult inpatients with CDI diagnosis treated with fidaxomicin versus oral or rectal vancomycin. Methods The patient population included adult inpatients 18 years or older admitted to a hospital within the healthcare system with CDI International Classification of Diseases, Tenth Revision (ICD-10) codes from January 1, 2017 to October 31, 2021. Data was obtained for inpatients with a discharge diagnosis of CDI and receiving fidaxomicin, oral or rectal vancomycin, or no receipt of either antibiotic. Readmission was defined as readmittance to the healthcare system within 8 weeks and a CDI diagnosis. Recurrence risk factors were defined as age 65 years or older, immunocompromised based on ICD-10 codes, and severe CDI defined as white blood cell count &amp;gt; 15 cells/mm3 PLUS serum creatinine &amp;gt; 1.5 mg/dL. Results More than 45,000 inpatients with a CDI diagnosis were evaluated. Administration rates of vancomycin, fidaxomicin, or no receipt of either was 76%, 6% and 18%, respectively. Median length of stay for vancomycin compared to fidaxomicin was 7 versus 9 days, respectively. Readmission rate was lower for total inpatients receiving vancomycin (14.6%) compared to fidaxomicin (18.5%), showing statistical significance (p &amp;lt; 0.0000005). Subgroup analyses were performed to evaluate inpatients with risk factors for CDI recurrence. Vancomycin had a lower readmission rate for all recurrence risk factor groups. Additionally, oral vancomycin had lower readmission rates for patients with more than one risk factor (13.4% vs. 16.1%). Conclusion The results of this study demonstrated that fidaxomicin did not result in a shorter length of stay or lower readmission rate compared to oral/rectal vancomycin. This study supports the continued use of oral/rectal vancomycin for CDI without preference for fidaxomicin. Disclosures All Authors: No reported disclosures.

Management of Upper Limb Amputation Rehabilitation: Synopsis of the 2022 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for Acquired Amputation.

Upper limb amputation can result in significant functional impairment necessitating a comprehensive rehabilitation approach throughout the continuum of care. In 2022, the Departments of Veteran Affairs and Defense completed an updated clinical practice guideline for the management of upper limb amputation rehabilitation. This practice guideline was developed by a workgroup of subject-matter experts from a variety of disciplines. Twelve key questions were developed by the workgroup using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) format to establish the scope of the literature review. Eighteen recommendations were developed through extensive review of the available literature and use of the Grading of Recommendations, Assessment, Development and Evaluation criteria. The strength of each recommendation was determined based on the quality of the research evidence and the additional domains of the Grading of Recommendations, Assessment, Development and Evaluation criteria. Of the 18 recommendations, 4 were found to have sufficient evidence to suggest for use of a particular rehabilitation management strategy. Thus, the 2022 Department of Veteran Affairs and Department of Defense clinical practice guideline provides updated, evidence-based information on the care and rehabilitation of persons with upper limb amputation. However, a significant lack of high-quality evidence in upper limb amputation rehabilitation limited evidence-based clinical guidance to assist healthcare providers in managing this population.

Changes inStreptococcus pneumoniaeSusceptibility in Wisconsin: Implications for Clinical Treatment Decisions for Respiratory Infections

Objective: In 2019, the American Thoracic Society and Infectious Diseases Society of America updated clinical practice guidelines for community-acquired pneumonia (CAP). In contrast to guidelines published in 2007, macrolide monotherapy for outpatients was made a conditional recommendation based on resistance levels. Local knowledge of current antimicrobial susceptibility is needed to guide management of CAP and other bacterial respiratory pathogens. The purpose of this study was to investigate antimicrobial susceptibility profiles and trending for Wisconsin Streptococcus pneumoniae isolates.Design: Multi-center laboratory surveillance, with testing at a central location utilizing standardized susceptibility testing protocols.Methods: Data published by the Wisconsin Department of Health Services (DHS) were augmented with data from the Surveillance of Wisconsin Organisms for Trends in Antimicrobial Resistance and Epidemiology (SWOTARE) program. Data were stratified by invasive or non-invasive sources, as well as DHS region and compared to data compiled from 2006-2010.Results: Susceptibility rates for ≥ 916 invasive S. pneumoniae assessed from 2016-2020 were greater than 91% for ceftriaxone, tetracycline, and fluoroquinolone agents and were generally higher than those from 354 non-invasive isolates. Low susceptibility rates were observed for invasive isolates of penicillin (78.7%) and erythromycin (64.8%) and were even lower for non-invasive isolates (73.8% and 59.9%, respectively). This erythromycin susceptibility rate was a significant reduction from that observed in 2006-2010 (80.4; P < 0.0002). 24.8% of isolates generated an erythromycin MIC ≥ 8 μg/mL. Statewide geographic variability was noted.Conclusions: Rates of S. pneumoniae susceptibility to parenteral penicillins and cephems, and oral tetracycline and fluoroquinolone agents, remain high throughout Wisconsin. However, low oral penicillin susceptibility rates, taken together with declining macrolide susceptibility rates, should cause clinicians to consider alternative treatment options for respiratory tract infections, especially with macrolides.

Clinical Practice Guidelines on Palliative Sedation Around the World: A Systematic Review.

Objective: The principal aim of this study was to identify, systematically and transparently, clinical practice guidelines (CPGs) on palliative sedation from around the world. Methods: A systematic search was performed using 5 databases, grey literature search tools, citation tracking, and contact with palliative care experts across the world. Current CPGs accredited by an international, national, or regional authority, published in English, German, French, or Italian, were subjected to content analysis. Results: In total, 35 CPGs from 14 countries and 1 international CPG were included in the analysis. The CPGs had diverse formal characteristics. Their thematic scope was difficult to analyze and compare because of differences in the terms and definitions of palliative sedation in those texts. We identified 3 main situations: (1) CPGs with a fully explicit thematic scope; (2) CPGs with a partially explicit thematic scope; and (3) CPGs without an explicit thematic scope. Several CPGs explicitly stated what forms of sedation were excluded from the text. However, this presentation was often confusing. Conclusion: Our review provides several pieces of information that could guide international reflections in this field, and be used to develop or update CPGs at all levels. Efforts should be made to clarify the thematic scope of each CPG on palliative sedation, in order to generate an understanding of the forms of this therapy addressed in the text.

A Preliminary Assessment of the Effects of Pharmacist-Driven Methadone Stewardship for the Treatment of Neonatal Abstinence Syndrome at a Tertiary Children's Hospital.

Lack of a standardized opioid wean guideline for the treatment of neonatal abstinence syndrome (NAS) has the potential to increase the length of the wean and subsequently the length of stay for neonates in the neonatal intensive care unit (NICU). The purpose of this study was to assess the effect of a pharmacist-driven methadone stewardship program for NAS treatment. The NAS stewardship program consisted of provider, pharmacist, and nursing education, a pharmacy surveillance system rule, and an updated clinical practice guideline. The pre- and post-intervention period were defined as patients admitted to the NICU from July 2019-October 2019 and August 2020-November 2020, respectively. The primary objective was to assess the effect of the stewardship program on the duration of opioid treatment in days. Secondary outcomes included number of dose titrations and length of hospital stay. A total of 21 patients were included in this study. Neonates treated following the adoption of the stewardship program (n = 8) experienced a 34% decreased median duration of treatment (29 days vs 19 days; p = 0.84). Secondary endpoints of median number of titrations and length of stay were decreased by 15% (1.5 titrations; p = 0.52) and 24% (8 days; p = 0.85), respectively, leading to an average cost savings of $60,020 per patient. Implementation of a standardized stewardship guideline for treatment of NAS resulted in a favorable decrease in all considered endpoints. Implications of the study further support the need for more evidence-based standardized guidelines for optimal treatment of patients with NAS.

Proyecto INCLIASMA fase II - Inercia clínica en asma en España

ObjectivesEighty percent of patients with asthma are poorly controlled. Despite the availability of updated clinical practice guidelines, poor asthma control and treatment continue to be detected. The main objective of the INCLIASMA phaseII study (INercia CLInica en ASMA) is to analyze the reality of asthma management in Spanish primary care (PC) clinics. As a secondary objective, it was proposed to establish a series of key recommendations in the management of patients with asthma, based on the conclusions of the panelists. Material and methodsCross-sectional descriptive, multicenter and non-randomized study, which was developed in two rounds, following the Delphi methodology. A specific online questionnaire was developed for the project with 41 items and divided into 5 blocks (diagnosis, control, adherence, treatment and referral criteria) and a group of PC physicians who were experts in asthma were asked to express their level of agreement or disagreement with the set of items in the questionnaire. From the results, the main existing controversies in the management of asthma in Spain were identified and practical recommendations were elaborated. ResultsTwenty-four panelists participated. There was a final consensus in 92.68% (38/41) of all the items collected in the questionnaire. The panelists concluded that it takes too long to diagnose asthma, and there is a high percentage of asthmatic patients without proper treatment, and therefore, without adequate control. Lack of time, care overload or therapeutic inertia are some of the determining factors in this situation. ConclusionsThe INCLIASMA phaseII study highlights the controversies found in routine clinical practice in asthma management, highlighting the continued need for training and offering consensus recommendations that seek to improve asthma management in our country.

Is Three Company or a Crowd? Comparing and Contrasting U.S. and European Clostridioidesdifficile Clinical Practice Guidelines.

In 2021, the American College of Gastroenterology (ACG), the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America (IDSA/SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published updated clinical practice guidelines (CPGs) for the management of Clostridioides difficile infections. The differences, sometimes subtle, between these guideline recommendations have caused some debate among clinicians. This paper delves into select key recommendations from each respective CPG and analyzes the differences and evidence associated with each. One primary difference between the CPGs is the preference given to fidaxomicin over vancomycin for initial treatment in non-severe and severe disease endorsed by IDSA/SHEA and ESCMID guidelines, while the ACG-sponsored CPGs do not offer a preference. The emphasis on cost effective data was also a noticeable difference between the CPGs and thus interpretation of the available evidence. When using guidelines to help support local practice or institutional treatment pathways, clinicians should carefully balance CPG recommendations with local patient populations and feasibility of implementation, especially when multiple guidelines for the same disease state exist.

Impact of Updated Clinical Practice Guidelines on Outpatient Treatment for Clostridioides difficile Infection and Associated Clinical Outcomes.

BackgroundThe 2017 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) Clostridium (Clostridioides) difficile infection (CDI) guideline update recommended treatment with fidaxomicin or vancomycin for CDI. We aimed to examine outpatient CDI treatment utilization before and after the guideline update and compare clinical outcomes associated with fidaxomicin versus vancomycin use.MethodsA pre-post study design was employed using Medicare data. CDI treatment utilization and clinical outcomes (4- and 8-week sustained response, CDI recurrence) were compared between patients indexed from April–September 2017 (preguideline period) and those indexed from April–September 2018 (postguideline period). Clinical outcomes associated with fidaxomicin versus vancomycin were compared using propensity score–matched analyses.ResultsFrom the pre- to postguideline period, metronidazole use decreased (initial CDI: 81.2% to 53.5%; recurrent CDI: 49.7% to 27.6%) while vancomycin (initial CDI: 17.9% to 44.9%; recurrent CDI: 48.1% to 66.4%) and fidaxomicin (initial CDI: 0.87% to 1.63%; recurrent CDI: 2.2% to 6.0%) use increased significantly (P < .001 for all). However, clinical outcomes did not improve. In propensity score–matched analyses, fidaxomicin versus vancomycin users had 4-week sustained response rates that were higher by 13.5% (95% confidence interval [CI], 4.0%–22.9%; P = .0058) and 30.0% (95% CI, 16.8%–44.3%; P = .0002) in initial and recurrent CDI cohorts, respectively. Recurrence rates were numerically lower for fidaxomicin in both cohorts.ConclusionsVancomycin use increased and metronidazole use decreased after the 2017 guideline update. Fidaxomicin use increased but remained low. Improved outcomes associated with fidaxomicin relative to vancomycin suggest benefits from its greater use in Medicare patients.

Abortion services and providers in Canada in 2019: results of a national survey.

Background:Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.Methods:We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.Results:Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.Interpretation:The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Updated S2k Clinical Practice Guideline on Non-alcoholic Fatty Liver Disease (NAFLD) issued by the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - April 2022 - AWMF Registration No.: 021-025.

List of Abbreviations AASLD: American Association for the Study of Liver Diseases AFP: Alpha-Fetoprotein AHA: American Heart Association AI: Artificial Intelligence ALD: Alcohol-related Liver Disease ALT: Alanineaminotransferase API: Active pharmaceutical ingredient APASL: Asian Pacific Association for the Study of the Liver APRI: AST/platelet ratio ASH: Alcoholic Steatohepatitis AST: Aspartate aminotransferase ATI: Attenuation Imaging AUC: Area under the curve AUROC: Area under the Receiver Operating Characteristic (ROC) Curve BMI: Body-Mass-Index CAP: Controlled Attenuation Parameter CDT: Carbohydrate-Deficient Transferrin CHE: Cholinesterase CIL: Cilofexor CMV: Cytomegalovirus CT: Computed Tomography CVC: Cenicriviroc DECT: Dual-Energy CT DM: Duodenal Mucosa DPP4: Dipeptidyl Peptidase 4 %EWL: Percentage Excess Weight Loss EASL: European Association for the Study of the Liver EBV: Epstein-Barr Virus ELF: Enhanced Liver Fibrosis ELIVATE: Study of Efficacy, Safety and Tolerability of the Combination of Tropifexor & Licogliflozin and Each Monotherapy, Compared with Placebo in Adult Patients with NASH and Liver Fibrosis. EPA: Ethyl Eicosapentaenic Acid ERCP: Endoscopic Retrograde Cholangiopancreatography ESG: Endoscopic sleeve gastroplasty EtG: Ethylglucuronid F1–F4: Stages of Liver Fibrosis 1–4 FASCINATE: Study of TVB-2640 in Subjects with Nonalcoholic Steatohepatitis (NASH) FASN: Fatty Acid Synthase FF: Fat Fraction FGF: Fibroblast Growth Factor FIR: Firsocostat FLI: Fatty Liver Index FLINT: The Farnesoid X Receptor (FXR) Ligand Obeticholic Acid in NASH Treatment Trial FLIGHT-FXR: Study of Safety and Efficacy of Tropifexor (LJN452) in Patients with Non-alcoholic Steatohepatitis FPG: Fasting Plasma Glucose FXR: Farnesoid X Receptor γ-GT: Gamma-Glutamyl Transferase GI: Gastrointestinal GLP-1: Glucagon-like Peptide 1 GOT: Glutamic-Oxaloacetic Transaminase GPT: Glutamate-Pyruvate Transaminase HA: Hyaluronic Acid HAV: Hepatitis A Virus HbA1c: Hemoglobin A1c HBV: Hepatitis B Virus HCC: Hepatocellular Carcinoma HCV: Hepatitis C Virus HDL: High-Density Lipoprotein HDV: Hepatitis D Virus HEV: Hepatitis E Virus HIS: Hepatic Steatosis Index Histo: Histology HOMA: Homeostasis Model Assessment HOMA-IR: Homeostasis Model Assessment – Insulin Resistance HVPG: Hepatic-Venous Pressure Gradient iCCa: Intrahepatic CholangiIocarcinoma IDF: International Diabetes Federation IQR: Interquartile Range LDL: Low-Density Lipoprotein LFS: Liver Fat Score LSG: Laparoscopic Sleeve Gastrectomy LT: Liver Transplantation MAFLD: Metabolic Dysfunction-Associated Fatty Liver Disease MDB: Mallory-Denk-Bodies Met: Metformin mo: Month MRCP: Magnetic Resonance Cholangiopancreatography MRE: Magnetic Resonance Elastography MRI: Magnetic Resonance Imaging MRS: Magnetic Resonance Spectroscopy n3 PUFA: n-3 Polyunsaturated Fatty Acid NAFLD: Non-Alcoholic Fatty Liver Disease NAS: NAFLD Activity Score NFS: NAFLD Fibrosis Score NASH: Non-Alcoholic Steatohepatitis NASH CRN: NASH Clinical Research Network NHLBI: National Heart, Lung and Blood Institute NPV: Negative Predictive Value​ OAGB: One-Anastomosis Gastric Bypass OCA: Obeticholic Acid OGTT: Oral Glucose Tolerance Test OTC: Over the Counter Pat.: Patient PCOS: Polycystic ovary Syndrom PDFF: Proton Density Fat-Fraction PEth: Phosphatidylethanol PIIINP: Procollagen III peptide Pio: Pioglitazone PMID: PubMed Identifier p. o.: per os PPAR: Peroxisome Proliferator-Activated Receptor PPV: Positive Predictive Value Prosp.: Prospective PUFA: Polyunsaturated Fatty Acids RYGB: Roux-Y Gastric Bypass SCD-1: Stearoyl-CoA Desaturase 1 SG: Sleeve Gastrectomy SGLT2: Sodium Dependent Glucose Co-transporter 2 SWE: Shear-Wave Elastography %TWL: Percentage Total Weight Loss T2DM: Type 2 Diabetes mellitus TANDEM: Study of Safety, Tolerability, and Efficacy of a Combination Treatment of LJN452 and CVC in Adult Patients ith NASH and Liver Fibrosis TBWL: Total Body Weight Loss TE: Transient Elastography TG: Triclyceride THRß: Thyroid Hormone Receptor-Beta TIMP-1: Tissue Inhibitor of Metalloproteinase-1 TZD: Thiazolidindione UDCA: Ursodeoxycholic Acid US: Ultrasound VCTE: Vibration-Controlled Transient Elastography Vit C: Vitamin C Vit E: Vitamin E