Evidence mapping of clinical practice guidelines recommendations and quality for depression in children and adolescents

Managing major depressive disorder in adolescents in primary care

ABSTRACT

Major depressive disorder (MDD) remains a significant risk to adolescent health and well-being, recently amplified by the COVID-19 pandemic. Access to adolescent mental health care services remains challenging in many areas, resulting in many adolescents diagnosed with MDD remaining untreated. Primary care providers are becoming increasingly crucial in promptly diagnosing and treating this concern. Various clinical guidelines can support clinicians in developing strategies for screening, diagnosing, and managing a vulnerable population with MDD. Standardized screenings, algorithms, and treatment guidelines can help improve the quality of life and functional impairment of those with MDD.

Efficacy and executive function of solution-focused brief therapy on adolescent depression

Objective

To investigate the efficacy and impact on executive function of Solution-Focused Brief Therapy (SFBT) in treating Major Depressive Disorder (MDD) in adolescents.

Methods

A total of 129 adolescents diagnosed with MDD were enrolled in the study. Out of these, 28 adolescents were assigned to the SFBT group, while 25 were part of the Active Control group (AC group), receiving psychodynamic psychotherapy. Executive function, depressive and anxiety symptoms were assessed at baseline, at the time of the third intervention, the sixth intervention, and the 10th intervention.

Results

After the third intervention, the scores of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) of the participants in the SFBT group decreased significantly, which had the cumulative effect at the 6th and 10th interventions. The verbal fluency task (VFT) performances of the SFBT group participants yielded significantly higher scores after the third intervention and remained increasing at the 6th and 10th interventions. The AC group steadily decreased after the intervention. Analysis of functional near-infrared spectroscopy (fNIRS) data revealed a progressive and significant increase in the average oxyhemoglobin (oxy-Hb) levels in the dorsolateral prefrontal cortex (DLPFC) in the SFBT group compared to the AC group after the 10th intervention.

Conclusions

SFBT might improve depressive and anxiety symptoms as well as executive function of adolescent depression.

Clinical trial registration

https://www.chictr.org.cn, identifier ChiCTR2300067909.

Evidence mapping of clinical practice guidelines on nutritional management for pressure injuries and their quality

CONTEXT

The safety and efficacy of nutritional management for pressure injuries (PIs) have been the subjects of ongoing interest. Some evidence demonstrated that nutrition is essential for skin and tissue viability, supporting tissue repair for healing the pressure injury.

OBJECTIVE

This investigation aimed to systematically review clinical practice guidelines (CPGs) for the nutritional management of PIs and furnish an evidence map to assess research trends and CPG gaps.

METHODS

The PubMed, Embase, and guidelines databases, and society websites were searched for CPGs for the nutritional management of PIs. The basic recommendations for the nutritional management of PIs, method quality, and reporting CPGs quality were identified and imported into Excel. Four researchers independently elucidated each CPG's quality via the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument and the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. All bubble charts were generated using Excel software.

RESULTS

This review included 12 CPGs with a combined 23 recommendations. The nutrition screening and assessment were summarized on the basis of the PI recommendations for 6 major items, 12 items on nutrition management, and 3 on PI education. The assessed CPGs had mixed quality, and the highest score  ± standard deviation based on the clarity of presentation was 83.46 ± 7.62, whereas the lowest mean score based on AGREE II applicability was 53.31 ± 16.90. Field 1 (basic information) in the RIGHT checklist had the greatest reporting rate (68.06%), whereas field 5 (review and quality assurance) had the lowest CPGs quality (41.67%).

CONCLUSION

This investigation furnishes an evidence map and provides new perspectives on the CPGs for the nutritional management of PIs. However, the CPGs included still need improvement, especially in the applicability and editorial independence domains.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA.

METHODS

The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript.

RESULTS

Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials.

CONCLUSIONS

Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

Real-world dose reduction of standard and modified FOLFIRINOX in metastatic pancreatic cancer: a systematic review, evidence-mapping, and meta-analysis

Background

FOLFIRINOX, used in metastatic pancreatic cancer (MPC), is highly efficacious but also toxic. Various dose modifications for FOLFIRINOX have been introduced to reduce toxicity. However, these studies lack a unified pattern for 'planned' dose modification, and the 'actually administered' dose varied more.

Objective

To map a 10-year trend for 'planned' and 'actual' doses of FOLFIRINOX and investigate the clinical outcomes according to dose modification.

Data sources and methods

A comprehensive systematic literature search was conducted from January 2011 to September 2021. All studies for FOLFIRINOX as first-line treatment in MPC were considered. Selected studies were firstly classified according to prospective versus retrospective research, secondly standard versus modified FOLFIRINOX, and thirdly 'planned' versus 'actual' dose. For evidence-mapping for the trend of dose modification, we developed a web-based interactive bubble-plot program (www.RDI-map.com). Objective response rate (ORR) and hematologic toxicity were set as endpoints for the comparison of clinical outcomes according to dose modification.

Results

A total of 37 studies were identified for evidence-mapping (11 prospective and 26 retrospective studies). There were 12 different types of 'planned' dose modification in FOLFIRINOX ranging 75-100% oxaliplatin, 75-100% irinotecan, 0-100% 5-fluorouracil (5-FU) bolus, and 75-133% 5-FU continuous injection. The 'actual' dose further decreased to 54-96%, 61-88%, 0-92%, and 63-98%, respectively. For the standard versus modified FOLFIRINOX, the ORR was 28.2% (95% CI: 22.5-33.9%) and 33.8% (95% CI: 30.3-37.3%), respectively (p = 0.100), and the incidence of febrile neutropenia was 11.6% (95% CI: 0-16.0%) and 5.5% (95% CI: 0-8.9%), respectively (p = 0.030).

Conclusions

RDI-map.com enables multifactorial evidence-mapping for practical FOLFIRINOX dose reduction. The pattern of dose modification was not consistent across studies, and there was a significant gap between the 'planned' and 'actual' doses. Modified FOLFIRINOX showed similar efficacy to the standard regimen with reduced incidence of febrile neutropenia.

Evidence of clinical benefit of WHO essential anticancer medicines for children, 2011-2021

Background

Access to essential cancer medicines is a key determinant of childhood cancer survival. WHO published the Model List of Essential Medicine for Children (EMLc) and updated it every two years since 2007 to promote better access to medicines for children. This study aimed to assess whether the inclusion of essential anticancer medicines for respective indications for children was based on evidence of significant clinical benefit between 2011 and 2021.

Methods

We identified all anticancer medicine indications added to the WHO EMLc Section 8 since 2011 and extracted evidence of benefit documented in the corresponding technical reports. Evidence in children was defined as evidence that included participants under 12, and graded into five levels, according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. We analyzed whether each anticancer medicine indication was listed with documented OS benefit or improvements in surrogate measures based on the highest level of documented evidence in children.

Findings

A total of 115 anticancer medicine indications were added to the EMLc from 2011 to 2021, of which 101 (87.8%) had some clinical evidence in children and 4 (3.5%) were added without any clinical evidence. Among the 101 medicine indications, none were added with level-1 evidence in children, and 43 (42.6%), 11 (10.9%), 41 (40.6%), and 6 (5.9%) were listed with level-2, level-3, level-4, and level-5 evidence in children, respectively. Only eight (7.9%) medicine indications were reported to have OS benefit, another 12 (11.9%) were reported to have improvements on surrogate measures, and 81 (80.2%) were listed in the EMLc without documented improvements in either OS or surrogate measures.

Interpretation

Most anticancer medicine indications of the WHO EMLc were added based on limited evidence of statistically significant clinical benefit in children. Our results suggest that WHO should refine requirements for clinical benefit criteria and permissible forms, quality, and reporting of evidence of essential anticancer medicines for children, specify whether anticancer medicine indications have required evidence of clinical benefit in children, and provide further details in its technical reports that summarise the available evidence.

Funding

Not applicable.

Consistency of recommendations for pharmacotherapy of rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory arthropathy. Recommendations for RA, specifically on pharmacotherapy, are essential in clinical practice. However, the direction and strength of recommendations are controversial across current clinical practice guidelines (CPGs) of RA.

Objective: To systematically analyze the consistency of recommendations regarding pharmacotherapy of RA across CPGs.

Methods: 11 electronic databases and websites were comprehensively searched from inception to 14 March 2022, to identify CPGs for diagnosis, therapy, and management of RA. Unambiguous and discrete specifications of the population-intervention-comparison (PIC) framework were used to classify the recommendations. Based on the PIC framework, consistency analyses across CPGs on pharmacotherapy of RA were performed. Two researchers reached a consensus on coding the direction and strength of each recommendation.

Results: Finally, 26 CPGs were included in this study, and 14 of them, which included pharmacotherapy, were performed consistency analysis. 1) 64 recommendations from 14 CPGs were classified into 18 PICs. 2) Seven PICs (38%) were consistent in direction and strength, 10 PICs (56%) were consistent in direction but inconsistent in strength, and one PIC (6%) was inconsistent in direction (hydroxychloroquine, HCQ). 3) Sensitivity analysis tested the robustness, and the inconsistency remained high.

Conclusion: The direction was highly consistent among the recommendations of pharmacotherapy for RA, but the strength was highly inconsistent. Reasons for the inconsistency need to be further investigated, and consistent recommendations could guide the pharmacotherapy of RA in clinical practice.

Dissemination of Acupuncture-Moxibustion Clinical Practice Guidelines among Clinical Practitioners: A Systematic Review of Quality Assessment Studies

Acupuncture clinical practice guidelines are authoritative medical recommendations developed by evaluating and integrating acupuncture-related evidence. However, their synthesis and dissemination are not integrated, and clinical practitioners require more credible effective evidence. The study aim was to systematically review problems disseminating acupuncture clinical practice guidelines to clinical practitioners, to facilitate evidence dissemination. This systematic review included searches of PubMed, EBSCO, Web of Science, and four major Chinese electronic databases (CNKI, VIP, Wanfang Database, and SinoMed) from inception to October 26, 2021. Two independent reviewers screened the literature, extracted information, and evaluated the quality of included studies. A systematic review was subsequently performed. Eleven studies were reviewed: nine (81.8%) cross-sectional surveys and two (18.2%) systematic reviews. The evaluated clinical practice guidelines differed across studies; seven studies (63.6%) evaluated guidelines for a specific disease, one (9.1%) evaluated guidelines for acupuncture therapies (e.g., moxibustion and fire acupuncture), one (9.1%) evaluated US acupuncture guidelines and recommendations, and two (18.2%) did not describe the guideline content. The included studies used different evaluation indicators. Guideline dissemination problems included lack of guideline standardization, unclear target population, mismatch between guidelines and application environment, lack of reliable health economics evaluation, poor quality content of the recommendations, lack of linkage between recommendations and evidence, and disassociation of recommendations from clinical practice et al. The development and publishing of credible acupuncture clinical practice guidelines is urgently needed to improve the usability of guidelines and standardize and disseminate tools for analysing information to clinical practitioners and to help the domestic and international acupuncture community to apply evidence to practice. Recommendations for promoting the dissemination of acupuncture clinical practice guidelines are to define clinical events suitable for the target population, to develop recommendations relevant to clinical practice, to improve the evidence evaluation index system, and to further standardize the method and process of formulating guidelines.