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Mannucci PM. Pros and cons of the ISTH treatment guidelines for hemophilia. J Thromb Haemost 2024; 22:2413-2415. [PMID: 38908833 DOI: 10.1016/j.jtha.2024.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/31/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
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2
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Miladinovic M, Reinhardt D, Hasle H, Goemans BF, Tomizawa D, Hitzler J, Klusmann JH. Guideline for treating relapsed or refractory myeloid leukemia in children with Down syndrome. Pediatr Blood Cancer 2024; 71:e31141. [PMID: 38965693 DOI: 10.1002/pbc.31141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 07/06/2024]
Abstract
Treatment of relapsed and refractory myeloid leukemia in Down syndrome (r/r ML-DS) poses significant challenges, as prognosis is dire and there is no established standard treatment. This guideline provides treatment recommendations based on a literature review and collection of expert opinions, aiming to improve overall and event-free survival of patients. Treatment options include fludarabine and cytarabine (FLA) ± gemtuzumab ozogamicin (GO), azacytidine (AZA) ± panobinostat, and hematopoietic stem cell transplantation (HSCT). Preferred approaches are AZA ± panobinostat for cases with low blast count or FLA ± GO for cases with high blast count, followed by HSCT after remission. Further research is crucial for the investigation of targeted therapies (e.g., BH3 mimetics, LSD1, JAK inhibitors).
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Affiliation(s)
- Milica Miladinovic
- Department of Pediatrics, Goethe-University Frankfurt, Frankfurt, Germany
| | - Dirk Reinhardt
- Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, Essen, Germany
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Bianca F Goemans
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Johann Hitzler
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Dekkers OM. Evidence, what's in a name? Some methodological remarks on the Grading of Recommendations Assessment, Development, and Evaluation approach for guideline development. J Thromb Haemost 2024; 22:2410-2412. [PMID: 38908830 DOI: 10.1016/j.jtha.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Section of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands.
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Ní Áinle F, DiMichele D, Falck-Ytter Y, Smit C, De Paula EV, Seth T, Chuansumrit A, Middeldorp S. ISTH clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology: considerations for practice management and implementation. J Thromb Haemost 2024; 22:2404-2409. [PMID: 38908829 DOI: 10.1016/j.jtha.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Fionnuala Ní Áinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland; Department of Haematology, Rotunda Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; University College Dublin School of Medicine, Dublin, Ireland.
| | - Donna DiMichele
- Donna DiMichele Consulting, LLC, Washington, DC, USA; Weill Cornell Medical College, New York, New York USA
| | - Yngve Falck-Ytter
- Case Western Reserve University, Cleveland, Ohio, USA; Department of Gastroenterology and Hepatology, Veterans Affairs North East Ohio Health Care System, Cleveland, Ohio, USA
| | - Cees Smit
- University of Amsterdam, Amsterdam, The Netherlands
| | - Erich V De Paula
- Department of Haematology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil; Coordenacao Geral de Sangue e Hemoderivados, Ministério da Saúde, Asa Norte, Brazil
| | - Tulika Seth
- Department of Haematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ampaiwan Chuansumrit
- International Hemophilia Treatment Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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5
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Rezende SM, Neumann I, Angchaisuksiri P, Awodu O, Boban A, Cuker A, Curtin JA, Fijnvandraat K, Gouw SC, Gualtierotti R, Makris M, Nahuelhual P, O'Connell N, Saxena R, Shima M, Wu R, Rosendaal FR. International Society on Thrombosis and Haemostasis clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology. J Thromb Haemost 2024; 22:2629-2652. [PMID: 39043543 DOI: 10.1016/j.jtha.2024.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Hemophilia is a rare congenital bleeding disorder that results from complete or partial deficiency of blood coagulation factor (F)VIII (hemophilia A) or FIX (hemophilia B) due to pathogenic variants in their coding genes. Hemophilia requires complex management. To date, there is no evidence-based clinical practice guideline on hemophilia treatment based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. OBJECTIVES This evidence-based clinical practice guideline from the International Society on Thrombosis and Haemostasis aims to provide an overview of evidence and support patients, caregivers, hematologists, pediatricians, other clinicians, researchers, and stakeholders in treatment decisions about congenital hemophilia A and B. METHODS The International Society on Thrombosis and Haemostasis formed a multidisciplinary guideline panel of physicians and patients with global representation, balanced to minimize potential bias from conflicts of interest. The panel prioritized a set of clinical questions and outcomes according to their importance for clinicians and patients. A methodological team supported the guideline development process, including searching for evidence and performing systematic reviews. The GRADE approach was used, including GRADE Evidence to Decision frameworks. The recommendations were subject to public comment. RESULTS The panel selected 13 questions, of which 11 addressed the treatment of hemophilia A and 2 the treatment of hemophilia B. Specifically, the panel addressed questions on prophylactic and episodic treatment with FVIII concentrates, bypassing agents, and nonfactor therapy (emicizumab) for hemophilia A (with and without inhibitors) as well as immune tolerance induction for hemophilia A. For hemophilia B, the panel addressed questions on prophylactic and episodic treatment of bleeding events with FIX concentrates. Agreement was reached for all 13 recommendations, of which 7 (54%) were based on evidence from randomized clinical trials, 3 (23%) on observational studies, and 3 (23%) on indirect comparisons. CONCLUSION Strong recommendations were issued for prophylactic over episodic treatment for severe and moderately severe hemophilia A and B. Only conditional recommendations were issued for the remaining questions. Future research should focus on direct treatment comparisons and the treatment of hemophilia B with and without inhibitors. Future updates of this guideline will provide an updated evidence synthesis on the current questions and focus on new FVIII and FIX concentrates, novel nonfactor therapies, and gene therapy for severe and nonsevere hemophilia A and B.
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Affiliation(s)
- Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ignacio Neumann
- School of Medicine, Universidad San Sebastian, Santiago, Chile
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Omolade Awodu
- Department of Hematology, School of Medicine, University of Benin, Benin City, Nigeria
| | - Ana Boban
- School of Medicine, University of Zagreb, Zagreb, Croatia; Department of Hematology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie A Curtin
- Department of Haematology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Samantha C Gouw
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Paula Nahuelhual
- Departamento de Evaluación de Tecnologías Sanitarias y Salud Basada en Evidencia, Ministerio de Salud, Santiago, Chile; Facultad de Medicina, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Niamh O'Connell
- Department of Haematology, National Coagulation Centre, St. James's Hospital Dublin, Dublin, Ireland; Department of Haematology, School of Medicine, Trinity College, Dublin, Ireland
| | - Renu Saxena
- Department of Hematopathology, Medanta Hospital, Gurugram, India
| | - Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Nara, Japan
| | - Runhui Wu
- Department of Hematology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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Homan M, Jones NL, Bontems P, Carroll MW, Czinn SJ, Gold BD, Goodman K, Harris PR, Jerris R, Kalach N, Kori M, Megraud F, Rowland M, Tavares M. Updated joint ESPGHAN/NASPGHAN guidelines for management of Helicobacter pylori infection in children and adolescents (2023). J Pediatr Gastroenterol Nutr 2024. [PMID: 39148213 DOI: 10.1002/jpn3.12314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 04/25/2024] [Accepted: 05/10/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Evolving epidemiological data and increasing antibiotic resistance mandate an update of the European and North American Societies of Pediatric Gastroenterology, Hepatology and Nutrition guidelines. METHODS Certainty of evidence and strength of recommendations were rated by experts according to the Grading of Recommendation Assessment, Development, and Evaluation approach. PICO (patient population, intervention, comparator, and outcome) questions were developed and voted on by the group. Recommendations were formulated using the Evidence to Decision framework. RESULTS The current literature supports many of the previous recommendations and several new recommendations. Invasive testing with strain antimicrobial susceptibility analysis is recommended for the diagnosis and selection of eradication therapy for H. pylori infection. Molecular methods are acceptable for detection of infection and of antibiotic resistance in gastric biopsy specimens. Reliable, noninvasive tests can be used as a screening method for children with history of gastric cancer in a first-degree relative. When investigating causes of chronic immune thrombocytopenic purpura, testing for H. pylori is no longer recommended. When investigating other diseases such as inflammatory bowel disease, celiac disease, or eosinophilic esophagitis, specific diagnostic biopsies for H. pylori infection are not indicated. However, if H. pylori is an incidental finding, treatment may be considered after discussing the risks and benefits. Treatment should be based on antibiotic antimicrobial susceptibility testing and, if unavailable, regimens containing clarithromycin should be avoided. CONCLUSIONS Due to decreasing prevalence of infection, increasing challenges with antibiotic resistance, and emerging evidence regarding complications of infection, clinicians must be aware of these recommended changes to appropriately manage H. pylori infection and its clinical sequelae in children.
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Affiliation(s)
- Matjaž Homan
- Faculty of Medicine, Children's Hospital in Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Nicola L Jones
- Division of Gastroenterology Hepatology and Nutrition, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Bontems
- Université Libre de Bruxelles, Hôpital Unversitaire des Enfants Reine Fabiola, Hôpitaux Universitaires de Bruxelles, Brussels, Belgium
| | - Matthew W Carroll
- Division of Gastroenterology and Nutrition, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Steven J Czinn
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Benjamin D Gold
- GI Care for Kids, LLC, Children's Center for Digestive Healthcare LLC, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Karen Goodman
- Faculty of Medicine and Dentistry, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Paul R Harris
- Department of Pediatric Gastroenterology and Nutrition, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Robert Jerris
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University of Lille, Lille, France
| | - Michal Kori
- Pediatric Gastroenterology, Kaplan Medical Center, Rehovot, and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Marion Rowland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Marta Tavares
- Unidade de Gastroenterologia, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, Portugal
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Li J, Yao H, Lu Y, Zhang S, Zhang Z. Chinese national clinical practice guidelines on prevention, diagnosis and treatment of early colorectal cancer. Chin Med J (Engl) 2024:00029330-990000000-01169. [PMID: 39104005 DOI: 10.1097/cm9.0000000000003253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND The incidence and mortality of colorectal cancer (CRC) in China are increasing in recent years. The clarified pathogenesis and detectable precancerous lesions of CRC make it possible to prevent, screen, and diagnose CRC at an early stage. With the development of endoscopic and surgical techniques, the choice of treatment for early CRC is also worth further discussion, and accordingly, a standard follow-up program after treatment needs to be established. METHODS This clinical practice guideline (CPG) was developed following the recommended process of the World Health Organization, adopting Grading of Recommendations Assessment, Development and Evaluation (GRADE) in assessing evidence quality, and using the Evidence to Decision framework to formulate clinical recommendations, thereby minimizing bias and increasing transparency of the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline's completeness and transparency. RESULTS This CPG comprises 46 recommendations concerning prevention, screening, diagnosis, treatment, and surveillance of CRC. In these recommendations, we have indicated protective and risk factors for CRC and made recommendations for chemoprevention. We proposed a suitable screening program for CRC based on the Chinese context. We also provided normative statements for the diagnosis, treatment, and surveillance of CRC based on existing clinical evidence and guidelines. CONCLUSIONS The 46 recommendations in this CPG are formed with consideration for stakeholders' values and preferences, feasibility, and acceptability. Recommendations are generalizable to resource-limited settings with similar CRC epidemiology pattern as China.
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Affiliation(s)
- Jingnan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100730, China
| | - Hongwei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Yun Lu
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266555, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing 100050, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing 100050, China
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Tignanelli CJ, Shah S, Vock D, Siegel L, Serrano C, Haut E, Switzer S, Martin CL, Rizvi R, Peta V, Jenkins PC, Lemke N, Thyvalikakath T, Osheroff JA, Torres D, Vawdrey D, Callcut RA, Butler M, Melton GB. A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury. Implement Sci 2024; 19:57. [PMID: 39103955 DOI: 10.1186/s13012-024-01386-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 07/14/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation. METHODS The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system. DISCUSSION The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics. TRIAL REGISTRATION Clinicaltrials.gov - NCT05628207. Prospectively registered 11/28/2022, https://classic. CLINICALTRIALS gov/ct2/show/NCT05628207 .
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Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA.
- Center for Quality Outcomes, Discovery and Evaluation, University of Minnesota, Minneapolis, MN, USA.
| | - Surbhi Shah
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - David Vock
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Lianne Siegel
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Carlos Serrano
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Elliott Haut
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Rubina Rizvi
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
| | - Vincent Peta
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Peter C Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas Lemke
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Thankam Thyvalikakath
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA
- Indiana University School of Dentistry, Indianapolis, IN, USA
| | | | - Denise Torres
- Department of Surgery, Geisinger Health, Danville, PA, USA
| | - David Vawdrey
- Department of Biomedical Informatics, Geisinger Health, Danville, PA, USA
| | - Rachael A Callcut
- Department of Surgery, UC Davis School of Medicine, Sacramento, CA, USA
| | - Mary Butler
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
- School of Publish Health, University of Minnesota, Minneapolis, MN, USA
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
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9
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Keller DS, Curtis N, Burt HA, Ammirati CA, Collings AT, Polk HC, Carrano FM, Antoniou SA, Hanna N, Piotet LM, Hill S, Cuijpers ACM, Tejedor P, Milone M, Andriopoulou E, Kontovounisios C, Leeds IL, Awad ZT, Barber MW, Al-Mansour M, Nassif G, West MA, Pryor AD, Carli F, Demartines N, Bouvy ND, Passera R, Arezzo A, Francis N. EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. Surg Endosc 2024; 38:4104-4126. [PMID: 38942944 PMCID: PMC11289045 DOI: 10.1007/s00464-024-10977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.
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Affiliation(s)
- Deborah S Keller
- Department of Digestive Surgery, University of Strasbourg, Strasbourg, FR, USA
| | - Nathan Curtis
- Surgical Unit, Dorset County Hospital, Dorchester, Dorset, UK
| | | | | | - Amelia T Collings
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Hiram C Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Francesco Maria Carrano
- Department of General and Minimally Invasive Surgery, Busto Arsizio Circolo Hospital, ASST-Valle Olona, Varese, Italy
| | - Stavros A Antoniou
- Department of General Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nader Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Sarah Hill
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patricia Tejedor
- Department of Colorectal Surgery, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marco Milone
- Department of Clinical and Surgical Gastrointestinal Diseases, University of Naples "Federico II", Via Pansini 5, Naples, Italy
| | - Eleni Andriopoulou
- Department of Surgery, Hellenic Red Cross Korgialeneio Benakeio NHS, Athens, Greece
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Campus and the Royal Marsden Hospital, London, UK
| | - Ira L Leeds
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | - Meghan Wandtke Barber
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Mazen Al-Mansour
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - George Nassif
- Department of Colorectal Surgery, AdventHealth, Orlando, FL, USA
| | - Malcolm A West
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Complex Cancer and Exenterative Service, University Hospitals Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton, Southampton, UK
| | - Aurora D Pryor
- Long Island Jewish Medical Center and System Chief for Bariatric Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Franco Carli
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | | | - Nicole D Bouvy
- Innovative Surgical Techniques, Endoscopic and Endocrine Surgery, Department of Surgery, Maastricht University Medical Center, Amsterdam, Netherlands
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Nader Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.
- The Griffin Institute, Northwick Park and St Mark's Hospital, Y Block, Watford Rd, Harrow, HA1 3UJ, UK.
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Medina-Aedo M, Beltran J, Valli C, Canelo-Aybar C, Song Y, Ballester M, Bowman-Busato J, Christogiannis C, Grammatikopoulou MG, Groene O, Heijmans M, Hoogendorn M, Killeen SL, Kontouli KM, Mavridis D, Miñambres I, Mueller BS, Niño de Guzman E, Noordman J, Orrego C, Perestelo-Perez L, Saz-Parkinson Z, Seitidis G, Suñol R, Tsokani S, Alonso-Coello P. Recommendations on self-management interventions for adults living with obesity: COMPAR-EU project. Clin Obes 2024; 14:e12667. [PMID: 38757917 DOI: 10.1111/cob.12667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/29/2024] [Accepted: 03/29/2024] [Indexed: 05/18/2024]
Abstract
Self-management interventions (SMIs) may improve disease management in adults living with obesity. We formulated evidence-based recommendations for SMIs within the context of the COMPAR-EU project. The multidisciplinary panel selected critical outcomes based on the COMPAR-EU core outcome set and established decision thresholds for each outcome. Recommendations were informed by systematic reviews of effects, cost-effectiveness, and a contextual assessment. To assess the certainty of the evidence and formulate the recommendations, we used the GRADE approach guidance. Overall, SMIs were deemed to have a small impact, but the absence of harmful effects and potential cumulative benefits indicated a favourable balance of effects, despite low certainty. SMIs showed variations in structure, intensity, and resource utilisation, but overall are likely to be cost-effective. Adapting SMIs to local contexts would enhance equity, acceptability, and feasibility, considering patients' values, and availability of resources and teamwork. Consequently, the panel made conditional recommendations favouring SMIs over usual care. The rigorous and explicit recommendations demonstrated the effectiveness of SMIs for adults living with obesity. However, the gaps in the literature influenced the panel to make only conditional recommendations in favour of SMIs. Further research is needed to strengthen the evidence base and improve recommendations' certainty and applicability.
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Affiliation(s)
- Melixa Medina-Aedo
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Jessica Beltran
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
| | - Carlos Canelo-Aybar
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Yang Song
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Marta Ballester
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
| | | | - Christos Christogiannis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Maria G Grammatikopoulou
- Immunonutrition and Clinical Nutrition Unit, Department of Rheumatology and Clinical Immunology, Medical School, University of Thessaly, Biopolis Campus, Larissa, Greece
| | | | - Monique Heijmans
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Martine Hoogendorn
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Katerina-Maria Kontouli
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Inka Miñambres
- Endocrinology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Barcelona, Spain
| | - Beate Sigrid Mueller
- Institute of General Practice, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ena Niño de Guzman
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Janneke Noordman
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Carola Orrego
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
| | - Lilisbeth Perestelo-Perez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Canary Islands, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | | | - Georgios Seitidis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Rosa Suñol
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
| | - Sofia Tsokani
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
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11
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Vikelis M, Rikos D, Argyriou AA, Papachristou P, Rallis D, Karapanayiotides T, Galanopoulos A, Spingos K, Dimisianos N, Giakoumakis E, Zavridis P, Notas K, Vlachos GS, Soldatos P, Bilias K, Xiromerisiou G, Rudolf J, Dermitzakis EV, Rapoport AM. Preferences and perceptions of 617 migraine patients on acute and preventive migraine treatment attributes and clinical trial endpoints. Expert Rev Neurother 2024; 24:815-826. [PMID: 38870024 DOI: 10.1080/14737175.2024.2365312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND To identify the preferences and perceptions of migraine patients for acute and preventive treatment options and to investigate which treatment outcomes are the most important. DESIGN AND METHODS The authors performed a choice-format survey in a cohort of migraine patients from Greece and Cyprus. A self-administered questionnaire developed in collaboration with the Greek Society of Migraine Patients was used. RESULTS Questionnaires were collected from 617 migraine patients. Efficacy was preferred over safety as the single most important parameter, both in acute and preventive treatment. When analyzing single outcomes, patients prioritized a complete pain remission at 1-hour post-dose for acute therapies. Regarding migraine prevention, a 75% reduction in frequency, intensity of pain, accompanying symptoms and acute medication intake were considered as most important. Conversely, outcomes routinely used in clinical trials, namely complete or partial pain remission at 2-hours post-dose for acute treatment and 50% or 30% reduction in migraine frequency for prevention, were not deemed particularly relevant. Tablet formulation was mostly preferred, both in acute and preventive treatment. Conclusion: Listening to patients' needs may add a piece of the puzzle that is generally missing in clinical practice and often explains the lack of adherence in both acute and preventative anti-migraine therapies.
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Affiliation(s)
- Michail Vikelis
- Mediterraneo Hospital Headache Clinic, Glyfada, Greece
- Greek Society of Migraine and Headache Patients, Athens, Greece
| | | | | | | | - Dimitrios Rallis
- Neurology Clinic, Peripheral General Hospital Tzaneio, Peiraias, Greece
| | - Theodoros Karapanayiotides
- 2nd Department of Neurology, University General Hospital of Thessaloniki AHEPA Medicine Sector, Thessaloniki, Greece
| | | | | | | | | | | | - Konstantinos Notas
- 1st Department of Neurology, University General Hospital of Thessaloniki AHEPA Medicine Sector, Thessaloniki, Greece
| | | | | | | | | | - Jobst Rudolf
- Neurology Department, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | | | - Alan M Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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12
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Pardessus P, Loiselle M, Brouns K, Horlin AL, Bruneau B, Maroun Y, Lagarde M, Deliere M, Julien-Marsollier F, Dahmani S. Intravenous lidocaine for postoperative analgesia management in paediatrics: A systematic review with meta-analysis of published studies. Eur J Anaesthesiol 2024:00003643-990000000-00209. [PMID: 39076006 DOI: 10.1097/eja.0000000000002046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
BACKGROUND The administration of intravenous lidocaine during the peri-operative period may improve pain management after paediatric surgery. OBJECTIVE To explore the decrease in postoperative pain intensity and opioid consumption associated with peri-operative lidocaine administration in the paediatric population. DESIGN A systematic review with meta-analysis of randomised controlled trials and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis. DATA SOURCES Extensive literature review. ELIGIBILITY CRITERIA This study includes clinical trials conducted during surgery that examined the effect of intravenous lidocaine compared with placebo on postoperative pain management. RESULTS Lidocaine administration decreased pain intensity in PACU (standardised mean difference (SMD) = -1.89 [-3.75, -0.03], I2 = 97%, P of I2 < 0.001) and on postoperative day 1 (SMD = -2.02 [-3.37, -0.66], I2 = 96%, P of I2 < 0.001, number of studies = 5). Lidocaine was associated with a decrease in opioid consumption on postoperative day 1 (SMD = -1.2 [-2.19, -0.2], I2 = 93%, P of I2 < 0.001) but not on postoperative day 2 (SMD = -1.73 [-3.9, 0.44], I2 = 96%, P of I2 < 0.001). GRADE analyses resulted in low-quality results. Subgroup analyses revealed that pain intensity in PACU and opioid consumption on postoperative day 1 decreased when lidocaine was administered during both the intra-operative and postoperative periods. CONCLUSIONS The use of lidocaine is associated with improved pain management. However, further studies are needed to increase the level of evidence and determine the optimal administration regimen for pain management.
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Affiliation(s)
- Pierre Pardessus
- From the University of Paris-Cité (PP, ML, KB, A-LH, BB, YM, ML, MD, FJ-M, SD), Department of Anaesthesia and Intensive Care (PP, ML, KB, A-LH, BB, YM, ML, MD, FJ-M, SD), FHU I2D2, Robert Debré University Hospital, Paris, France (PP, ML, KB, A-LH, BB, YM, ML, MD, FJ-M, SD)
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13
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Jessen LR, Werner M, Singleton D, Prior C, Foroutan F, Ferran AA, Arenas C, R Bjørnvad C, Lavy E, Allerton F, Allensbach K, Guardabassi L, Unterer S, Bodnárová T, Windahl U, Brennan ML, Weese JS, Scahill K. European Network for Optimization of Veterinary Antimicrobial Therapy (ENOVAT) guidelines for antimicrobial use in canine acute diarrhoea. Vet J 2024; 307:106208. [PMID: 39074542 DOI: 10.1016/j.tvjl.2024.106208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
Acute diarrhoea is a common presentation in dogs, and a common reason for antimicrobial prescription and nutraceutical use. This evidence-based guideline provides recommendations for antimicrobial and probiotic treatment of canine acute diarrhoea (CAD). A multidisciplinary panel developed the recommendations by adhering to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The opinions of stakeholders (general veterinary practitioners and dog owners) were collected and incorporated to ensure the applicability of this guideline. Four strong recommendations informed by high certainty evidence, and three conditional recommendations informed by very low or low certainty evidence, were drafted by the panel, along with an ungraded section on diagnostic work-up of dogs with acute diarrhoea. The ENOVAT guidelines initiative encourages national or regional guideline makers to use the evidence presented in this document, and the supporting systematic review, to draft national or local guidance documents.
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Affiliation(s)
- L R Jessen
- Department of Veterinary Clinical Science, University of Copenhagen, Frederiksberg C 1870, Denmark.
| | - M Werner
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich 8057, Switzerland
| | - D Singleton
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, CH64 7TE, United Kingdom
| | - C Prior
- Willows Veterinary Centre & Referral Centre, Solihull B90 4NH, United Kingdom
| | - F Foroutan
- Faculty of Health Sciences, McMasters University, ON L8S 4L8, Canada
| | - A A Ferran
- INTHERES, Université de Toulouse, INRAE, ENVT, Toulouse 31076, France
| | - C Arenas
- Internal Medicine Service, AniCura Valencia Sur Hospital Veterinario, Valencia 46460, Spain; VetCT Teleconsulting, Cambridge CB30FA, United Kingdom
| | - C R Bjørnvad
- Department of Veterinary Clinical Science, University of Copenhagen, Frederiksberg C 1870, Denmark
| | - E Lavy
- Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot 76100, Israel
| | - F Allerton
- Willows Veterinary Centre & Referral Centre, Solihull B90 4NH, United Kingdom
| | - K Allensbach
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA 50010, United States
| | - L Guardabassi
- Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg C 1870, Denmark
| | - S Unterer
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich 8057, Switzerland
| | - T Bodnárová
- Veterinary Clinic Podebrady, Poděbrady 290 01, Czech Republic; Centre for Evidence-based Veterinary Medicine, The University of Nottingham, LE12 5RD, United Kingdom
| | - U Windahl
- Department of Animal Health and Antimicrobial Strategies, National Veterinary Institute (SVA), Uppsala SE-75189, Sweden
| | - M L Brennan
- Centre for Evidence-based Veterinary Medicine, The University of Nottingham, LE12 5RD, United Kingdom
| | - J S Weese
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, ON N1G2W1, Canada
| | - K Scahill
- Evidensia Södra Djursjukhuset Kungens Kurva, Månskärarvägen 13, Kungens Kurva 14175, Sweden; University of Edinburgh, College of Medicine and Veterinary Medicine, Edinburgh EH16 4SB, United Kingdom
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14
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Blokzijl J, Pisters MF, Aspdahl M, de Boer W, Dybvik Matlary RE, Douma-van Riet D, de Kleijn P, Lobet S, Loughnane P, McLaughlin P, Bladen M, Roche S, Stephensen D, van Vlimmeren L, van Vulpen LFD, Timmer MA. A clinical practice guideline for primary care physiotherapy in patients with haemophilia. Haemophilia 2024. [PMID: 38987021 DOI: 10.1111/hae.15065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/30/2024] [Accepted: 05/21/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION As a result of centralisation of haemophilia care to a limited number of intramural settings, many persons with haemophilia have to travel long distances to attend their haemophilia specialised treatment centre. However, regular physiotherapy treatment can be provided by primary care physiotherapists in the person's own region. Due to the rarity of the disease most primary care physiotherapists have limited experience with this population. This study aims to provide a clinical practice guideline for primary care physiotherapists working with persons with bleeding disorders. METHOD A list of the most urgent key-questions was derived from a previous study. Literature was summarised using the grading of recommendations assessment, development, and evaluation (GRADE) evidence-to-decision framework. Recommendations were drafted based on four 90 min consensus meetings with expert physiotherapists. Recommendations were finalised after feedback and >80% consensus of all stakeholders (including PWH, physiotherapists, haematologists and the corresponding societies). RESULTS A list of 82 recommendations was formulated to support primary care physiotherapists when treating a person with a bleeding disorder. These recommendations could be divided into 13 categories: two including recommendations on organisation of care, six on therapy for adult patients with bleeding disorders and five on therapy adaptations for paediatric care. Therapy recommendations included treatment after a joint- or muscle bleed, haemophilic arthropathy, chronic synovitis, non-haemophilia related conditions and orthopaedic surgery. CONCLUSION An evidence-based practice guideline, based on current evidence from literature and clinical expertise, has been developed for primary care physiotherapists treating a person with haemophilia. To improve care, the recommendations should be implemented in daily practice.
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Affiliation(s)
- Johan Blokzijl
- Centre for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martijn F Pisters
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
- Research Group Empowering Healthy Behaviour, Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands
| | - Magnus Aspdahl
- Women's Health and Allied Health Professionals Theme, Pediatric occupational therapy and physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Wypke de Boer
- Department of Rehabilitation, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ruth Elise Dybvik Matlary
- Department of Clinical Service, Section for physiotherapy, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Piet de Kleijn
- Centre for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Sébastien Lobet
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Neuromusculoskeletal Lab (NMSK), Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain (UCLouvain), Ottignies-Louvain-la-Neuve, Belgium
| | | | - Paul McLaughlin
- Research Department of Haematology, University College London, London, UK
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Melanie Bladen
- Haemophilia Center, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Great Ormond St, Institute of Child Health, University College London, London, UK
| | - Sheila Roche
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - David Stephensen
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, UK
| | - Leo van Vlimmeren
- Department of Rehabilitation, Paediatric Physical Therapy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lize F D van Vulpen
- Centre for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Merel A Timmer
- Centre for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands
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15
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Zantek ND, Steiner ME, Teruya J, Kreuziger LB, Raffini L, Muszynski JA, Alexander PMA, Gehred A, Lyman E, Watt K. Recommendations on Monitoring and Replacement of Antithrombin, Fibrinogen, and Von Willebrand Factor in Pediatric Patients on Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e35-e43. [PMID: 38959358 PMCID: PMC11216379 DOI: 10.1097/pcc.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic review informed, modified Delphi consensus regarding monitoring and replacement of specific coagulation factors during pediatric extracorporeal membrane oxygenation (ECMO) support for the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES A structured literature search was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2020, with an update in May 2021. STUDY SELECTION Included studies assessed monitoring and replacement of antithrombin, fibrinogen, and von Willebrand factor in pediatric ECMO support. DATA EXTRACTION Two authors reviewed all citations independently, with conflicts resolved by a third reviewer if required. Twenty-nine references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. A panel of 48 experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. We developed one weak recommendation and four expert consensus statements. CONCLUSIONS There is insufficient evidence to formulate recommendations on monitoring and replacement of antithrombin, fibrinogen, and von Willebrand factor in pediatric patients on ECMO. Optimal monitoring and parameters for replacement of key hemostasis parameters is largely unknown.
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Affiliation(s)
- Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, MN
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute and Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Raffini
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Kevin Watt
- Division of Critical Care, Department of Pediatrics and Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, UT
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16
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Cashen K, Saini A, Brandão LR, Le J, Monagle P, Moynihan KM, Ryerson LM, Gehred A, Lyman E, Muszynski JA, Alexander PMA, Dalton HJ. Anticoagulant Medications: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e7-e13. [PMID: 38959355 PMCID: PMC11216397 DOI: 10.1097/pcc.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the medications used for anticoagulation for pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE (PEACE). DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Included studies assessed anticoagulation used in pediatric ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third reviewer adjudicating any conflicts. Eighteen references were used for data extraction as well as for creation of recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements, or good practice statements for anticoagulation during pediatric ECMO. A web-based modified Delphi process was used to build consensus via the Research and Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. Two recommendations, two consensus statements, and one good practice statement were developed, and, in all, agreement greater than 80% was reached. CONCLUSIONS There is insufficient evidence to formulate optimal anticoagulation therapy during pediatric ECMO. Additional high-quality research is needed to inform evidence-based practice for anticoagulation during pediatric ECMO.
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Affiliation(s)
- Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Paul Monagle
- University of Melbourne, Melbourne, VIC, Australia
- Kids Cancer Centre Sydney Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Westmead Children's Hospital, Sydney, NSW, Australia
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
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17
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Ozment C, Alexander PMA, Chandler W, Emani S, Hyslop R, Monagle P, Muszynski JA, Willems A, Gehred A, Lyman E, Steffen K, Thiagarajan RR. Anticoagulation Monitoring and Targets: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e14-e24. [PMID: 38959356 PMCID: PMC11216399 DOI: 10.1097/pcc.0000000000003494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding anticoagulation monitoring assays and target levels in pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Anticoagulation monitoring of pediatric patients on ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool or the revised Cochrane risk of bias for randomized trials, as appropriate and the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for clinical recommendations focused on anticoagulation monitoring and targets, using a web-based modified Delphi process to build consensus (defined as > 80% agreement). One weak recommendation, two consensus statements, and three good practice statements were developed and, in all, agreement greater than 80% was reached. We also derived some resources for anticoagulation monitoring for ECMO clinician use at the bedside. CONCLUSIONS There is insufficient evidence to formulate optimal anticoagulation monitoring during pediatric ECMO, but we propose one recommendation, two consensus and three good practice statements. Overall, the available pediatric evidence is poor and significant gaps exist in the literature.
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Affiliation(s)
- Caroline Ozment
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Wayne Chandler
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Robert Hyslop
- Heart Institute, Children's Hospital of Colorado, Aurora, CO
| | - Paul Monagle
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
- Heart Institute, Children's Hospital of Colorado, Aurora, CO
- University of Melbourne, Melbourne, VIC, Australia
- Kids Cancer Centre Sydney Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Royal Children's Hospital, Melbourne, VIC, Australia
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus OH
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus OH
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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18
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Willems A, Anders MM, Garcia AV, Vogel AM, Yates AR, Muszynski JA, Alexander PMA, Steffen K, Emani S, Gehred A, Lyman E, Raman L. Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e53-e65. [PMID: 38959360 PMCID: PMC11216378 DOI: 10.1097/pcc.0000000000003490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION ECMO anticoagulation and hemostasis management in the perioperative period and during procedures. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented. CONCLUSIONS Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.
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Affiliation(s)
- Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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19
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Rintoul NE, McMichael ABV, Bembea MM, DiGeronimo R, Patregnani J, Alexander PMA, Muszynski JA, Steffen K, Gehred A, Lyman E, Cheifetz IM. Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e66-e77. [PMID: 38959361 PMCID: PMC11216396 DOI: 10.1097/pcc.0000000000003489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.
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Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Jason Patregnani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Barbara Bush Children's Hospital, Portland, ME
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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20
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Moynihan KM, Ryerson LM, Le J, Nicol K, Watt K, Gadepalli SK, Alexander PMA, Muszynski JA, Gehred A, Lyman E, Steiner ME. Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e44-e52. [PMID: 38959359 PMCID: PMC11216380 DOI: 10.1097/pcc.0000000000003491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs). DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented. CONCLUSIONS Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
| | - Lindsay M Ryerson
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
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21
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Himebauch AS, Priest JR, Annich GM, McMullan DM, Turner DA, Muszynski JA, Alexander PMA, Paden ML, Gehred A, Lyman E, Said AS. The Influence of the Extracorporeal Membrane Oxygenation Circuit and Components on Anticoagulation Management: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e1-e6. [PMID: 38959354 PMCID: PMC11216392 DOI: 10.1097/pcc.0000000000003496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the influence of extracorporeal membrane oxygenation (ECMO) circuit components on anticoagulation practices for pediatric ECMO for the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Management of ECMO anticoagulation in the setting of different ECMO circuit components. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twenty-nine references were used for data extraction and informed recommendations, evidence-based consensus statements, and good practice statements. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements or good practice statements for the influence of ECMO circuit and components on anticoagulation management. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One good practice statement, 2 weak recommendations, and 2 consensus statements are presented. CONCLUSIONS The incorporation of new component technologies into clinical practice has outpaced clinical investigations of anticoagulation strategies for pediatric ECMO. Future investigations should leverage academic and industrial collaborations, translational platforms, and modern biostatistical methods to improve patient outcomes.
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Affiliation(s)
- Adam S Himebauch
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John R Priest
- Department of Respiratory Care, ECMO Program, Boston Children's Hospital, Boston, MA
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - David A Turner
- American Board of Pediatrics, Chapel Hill, NC
- Division of Pediatric Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Matthew L Paden
- Division of Pediatric Critical Care, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Ahmed S Said
- Division of Pediatric Critical Care, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO
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22
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Nellis ME, Moynihan KM, Sloan SR, Delaney M, Kneyber MCJ, DiGeronimo R, Alexander PMA, Muszynski JA, Gehred A, Lyman E, Karam O. Prophylactic Transfusion Strategies in Children Supported by Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e25-e34. [PMID: 38959357 PMCID: PMC11216389 DOI: 10.1097/pcc.0000000000003493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding prophylactic transfusions in neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2020, with an update in May 2021. STUDY SELECTION Included studies assessed use of prophylactic blood product transfusion in pediatric ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Thirty-three references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS The evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements or good practice statements for prophylactic transfusion strategies for children supported with ECMO. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. We developed two good practice statements, 4 weak recommendations, and three expert consensus statements. CONCLUSIONS Despite the frequency with which pediatric ECMO patients are transfused, there is insufficient evidence to formulate evidence-based prophylactic transfusion strategies.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Katie M Moynihan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology and Pediatrics, George Washington University Health Sciences, Washington, DC
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- The Ohio State University of Medicine, Columbus, OH
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Steven R Sloan
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology and Pediatrics, George Washington University Health Sciences, Washington, DC
| | - Martin C J Kneyber
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- The Ohio State University of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Oliver Karam
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
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23
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Shanmugalingam R, Barrett HL, Beech A, Bowyer L, Crozier T, Davidson A, Dekker Nitert M, Doyle K, Grzeskowiak L, Hall N, Cheikh Hassan HI, Hennessy A, Henry A, Langsford D, Lee VW, Munn Z, Peek MJ, Said JM, Tanner H, Taylor R, Ward M, Waugh J, Yen LL, Medcalf E, Bell KJ, Ackermann D, Turner R, Makris A. A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline. Med J Aust 2024; 220:582-591. [PMID: 38763516 DOI: 10.5694/mja2.52312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) affect up to 10% of all pregnancies annually and are associated with an increased risk of maternal and fetal morbidity and mortality. This guideline represents an update of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) guidelines for the management of hypertensive disorders of pregnancy 2014 and has been approved by the National Health and Medical Research Council (NHMRC) under section 14A of the National Health and Medical Research Council Act 1992. In approving the guideline recommendations, NHMRC considers that the guideline meets NHMRC's standard for clinical practice guidelines. MAIN RECOMMENDATIONS A total of 39 recommendations on screening, preventing, diagnosing and managing HDP, especially preeclampsia, are presented in this guideline. Recommendations are presented as either evidence-based recommendations or practice points. Evidence-based recommendations are presented with the strength of recommendation and quality of evidence. Practice points were generated where there was inadequate evidence to develop specific recommendations and are based on the expertise of the working group. CHANGES IN MANAGEMENT RESULTING FROM THE GUIDELINE This version of the SOMANZ guideline was developed in an academically robust and rigorous manner and includes recommendations on the use of combined first trimester screening to identify women at risk of developing preeclampsia, 14 pharmacological and two non-pharmacological preventive interventions, clinical use of angiogenic biomarkers and the long term care of women who experience HDP. The guideline also includes six multilingual patient infographics which can be accessed through the main website of the guideline. All measures were taken to ensure that this guideline is applicable and relevant to clinicians and multicultural women in regional and metropolitan settings in Australia and New Zealand.
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Affiliation(s)
| | - Helen L Barrett
- Royal Hospital for Women, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | - Amanda Beech
- Royal Hospital for Women, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | | | - Tim Crozier
- Monash Medical Centre, Melbourne, VIC
- Monash University, Melbourne, VIC
| | - Amanda Davidson
- Australian Pregnancy Hypertension Foundation Limited, Sydney, NSW
| | | | | | | | | | | | - Annemarie Hennessy
- Western Sydney University, Sydney, NSW
- Campbelltown Hospital, Sydney, NSW
| | - Amanda Henry
- University of New South Wales, Sydney, NSW
- St George Hospital, Sydney, NSW
| | - David Langsford
- Grampians Health, Ballarat, VIC
- University of Melbourne, Ballarat, VIC
| | - Vincent Ws Lee
- University of Sydney, Sydney, NSW
- Westmead Hospital, Sydney, NSW
| | - Zachary Munn
- Health Evidence Synthesis, Recommendations and Impact (HESRI), University of Adelaide, Adelaide, SA
| | - Michael J Peek
- Australian National University, Canberra, ACT
- Centenary Hospital for Women and Children, Canberra, ACT
| | - Joanne M Said
- University of Melbourne, Ballarat, VIC
- Joan Kirner Women's and Children's Sunshine Hospital, Melbourne, VIC
| | - Helen Tanner
- Royal Brisbane and Women's Hospital, Brisbane, QLD
| | | | | | - Jason Waugh
- University of Auckland, Auckland, New Zealand
| | - Linda Ly Yen
- Te Whatu Ora - Health New Zealand Counties Manukau, Auckland, New Zealand
| | | | | | | | - Robin Turner
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Angela Makris
- Liverpool Hospital, Sydney, NSW
- Western Sydney University, Sydney, NSW
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24
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Kumar SS, Collings AT, Wunker C, Athanasiadis DI, DeLong CG, Hong JS, Ansari MT, Abou-Setta A, Oliver E, Berghella V, Alli V, Hassan I, Hollands C, Sylla P, Slater BJ, Palazzo F. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2024; 38:2947-2963. [PMID: 38700549 PMCID: PMC11133165 DOI: 10.1007/s00464-024-10810-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/21/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Claire Wunker
- Department of Surgery, Saint Louis University, Saint Louis, MO, USA
| | | | - Colin G DeLong
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Julie S Hong
- Department of Surgery, NewYork-Presbyterian Queens, New York, NY, USA
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Emily Oliver
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Department of Obstetrics & Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vamsi Alli
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Imran Hassan
- Department of Surgery, Mercy Medical Center Cedar Rapids, Cedar Rapids, IA, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Health System, New York, NY, USA
| | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA.
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Kumar SS, Collings AT, Lamm R, Haskins IN, Scholz S, Nepal P, Train AT, Athanasiadis DI, Pucher PH, Bradley JF, Hanna NM, Quinteros F, Narula N, Slater BJ. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc 2024; 38:2974-2994. [PMID: 38740595 DOI: 10.1007/s00464-024-10813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pramod Nepal
- Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | - Philip H Pucher
- School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Nisha Narula
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
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Calzavara-Pinton P, Tonon F, Rossi M. Commentary to the publication of the Italian adaptation of the EuroGuiDerm guidelines for Atopic Dermatitis. Ital J Dermatol Venerol 2024; 159:219-222. [PMID: 38743379 DOI: 10.23736/s2784-8671.24.07669-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
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Vieira RJ, Sousa‐Pinto B, Bognanni A, Yepes‐Nuñez JJ, Zhang Y, Lityńska J, Sadowska E, Borowiack E, Samolinski B, Togias A, Zuberbier T, Bousquet J, Schünemann HJ. Embedding patients' values and preferences in guideline development for allergic diseases: The case study of Allergic Rhinitis and its Impact on Asthma 2024. Clin Transl Allergy 2024; 14:e12377. [PMID: 38862272 PMCID: PMC11166500 DOI: 10.1002/clt2.12377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024] Open
Abstract
Recommendations for or against the use of interventions need to consider both desirable and undesirable effects as well as patients' values and preferences (V&P). In the decision-making context, patients' V&P represent the relative importance people place on the outcomes resulting from a decision. Therefore, the balance between desirable and undesirable effects from an intervention should depend not only on the difference between benefits and harms but also on the value that patients place on them. V&P are therefore one of the criteria to be considered when formulating guideline recommendations in the Evidence-to-Decision framework developed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group. Patients' V&P may be quantified through utilities, which can be elicited using direct methods (e.g., standard gamble or time trade-off) or indirect methods (using validated instruments to measure health-related quality of life, such as EQ-5D). The GRADE approach recommends conducting systematic reviews to summarise all the available evidence and assess the degree of certainty on V&P. In this article, we discuss the importance of considering patients' V&P and provide examples of how they are considered in the 2024 person-centred Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.
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Affiliation(s)
- Rafael José Vieira
- Department of Community MedicineInformation and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
- Centre for Health Technology and Services ResearchHealth Research Network (CINTESIS@RISE)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community MedicineInformation and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
- Centre for Health Technology and Services ResearchHealth Research Network (CINTESIS@RISE)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineEvidence in Allergy GroupMcMaster UniversityHamiltonOntarioCanada
| | - Juan José Yepes‐Nuñez
- School of MedicineUniversidad de los AndesBogotáColombia
- Pulmonology ServiceInternal Medicine SectionFundación Santa Fe de BogotáUniversity HospitalBogotáColombia
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | | | | | | | - Boleslaw Samolinski
- Department of Prevention of Environmental Hazards, Allergology and ImmunologyMedical University of WarsawWarsawPoland
| | - Alkis Togias
- Division of Allergy, Immunology, and Transplantation (DAIT)National Institute of Allergy and Infectious DiseasesNIHBethesdaMarylandUSA
| | - Torsten Zuberbier
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
- Fraunhofer Cluster of Excellence for Immune‐Mediated Diseases CIMDFrankfurtGermany
| | - Jean Bousquet
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
- Fraunhofer Cluster of Excellence for Immune‐Mediated Diseases CIMDFrankfurtGermany
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Michael G. DeGroote Cochrane Canada & McMaster GRADE CentresMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
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28
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Holland AE, Spathis A, Marsaa K, Bausewein C, Ahmadi Z, Burge AT, Pascoe A, Gadowski AM, Collis P, Jelen T, Reilly CC, Reinke LF, Romero L, Russell AM, Saggu R, Solheim J, Vagheggini G, Vandendungen C, Wijsenbeek M, Tonia T, Smallwood N, Ekström M. European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness. Eur Respir J 2024; 63:2400335. [PMID: 38719772 DOI: 10.1183/13993003.00335-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/19/2024] [Indexed: 06/30/2024]
Abstract
Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.
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Affiliation(s)
- Anne E Holland
- Departments of Physiotherapy and Respiratory Medicine, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Monash University, Melbourne, Australia
- Institute for Breathing and Sleep, Melbourne, Australia
| | - Anna Spathis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kristoffer Marsaa
- Department of Multidisease, North Zealand Hospital, Copenhagen University, Hilleroed, Denmark
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Zainab Ahmadi
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Angela T Burge
- School of Translational Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Amy Pascoe
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Adelle M Gadowski
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Phil Collis
- CPROR Birmingham University, Birmingham, UK
- Patient Advisory Group, European Lung Foundation, Sheffield, UK
| | - Tessa Jelen
- Patient Advisory Group, European Lung Foundation, Sheffield, UK
| | - Charles C Reilly
- Department of Physiotherapy, King's College Hospital, London, UK
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Lynn F Reinke
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Lorena Romero
- The Ian Potter Library, Alfred Health, Melbourne, Australia
| | - Anne-Marie Russell
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Birmingham Regional NHS Interstitial Lung Disease and Occupational Lung Disease Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravijyot Saggu
- Pharmacy Medicines Management Team, Central London Community Healthcare Trust, London, UK
| | - John Solheim
- EU-PFF - European Pulmonary Fibrosis Federation, Overijse, Belgium
- LHL-IPF, Jessheim, Norway
| | - Guido Vagheggini
- Department of Internal Medicine and Medical Specialties, Respiratory Failure Pathway, Azienda USL Toscana Nordovest, Pisa, Italy
- Fondazione Volterra Ricerche ONLUS, Volterra, Italy
| | - Chantal Vandendungen
- EU-PFF - European Pulmonary Fibrosis Federation, Overijse, Belgium
- ABFFP - Association Belge Francophone Contre la Fibrose Pulmonaire, Rebecq, Belgium
| | - Marlies Wijsenbeek
- Department of Respiratory Medicine, Erasmus University Medical Center, Center of Excellence for Interstitial Lung Disease, Rotterdam, The Netherlands
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Natasha Smallwood
- School of Translational Medicine, Monash University, Melbourne, Australia
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
- Joint last authors
| | - Magnus Ekström
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Joint last authors
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Holten M, Shakur Z, Sultan S, Nakib N, Warlick C, Dahm P. Under-representation of Diversity on American Urological Association and European Association of Urology Guideline Panels. Urology 2024:S0090-4295(24)00413-8. [PMID: 38823650 DOI: 10.1016/j.urology.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/26/2024] [Accepted: 05/23/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE To assess the panel composition of the 2 most important guideline developers in urology as equity and acceptability, important domains in clinical guideline development, require broad stakeholder representation. METHODS Following a predefined protocol, we identified all current AUA and EAU guideline documents. Two authors independently abstracted data including guideline topic, number and roles of panel members, voting status, and academic rank. We determined panel member's gender (woman, man, or nonbinary) and racialization (White or non-White) status based on name, internet picture, pronouns used, bios available, and gender listed on their profile. RESULTS We identified 31 AUA and 20 EAU guidelines for inclusion. Median panel size was 19 (interquartile range [IQR]: 17; 21) with 12 (IQR: 10; 14) voting members. The average composition of voting panels was predominantly male (81.8%) and White (86.8%). Eleven guideline panels (21.6%) did not include any women, and 9 (17.6%) panels had no representation of individuals from non-White groups. While gender distribution was similar among guidelines of the 2 organizations, the AUA included more voting members from non-White groups (14.3% vs 8.0%; P = .010). Analysis of the AUA panel composition over time revealed stable proportions of female and non-White individuals. CONCLUSION Both AUA and EAU guidelines exhibit insufficient representation of females and non-White individuals, with no evident improvement observed over time. Implementing more transparent processes that advocate for diverse panel representation may enhance the incorporation of stakeholder values and preferences, thereby improving the dissemination and adoption of guidelines.
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Affiliation(s)
- Matthew Holten
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN
| | - Zahrah Shakur
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN
| | - Shahnaz Sultan
- Department of Medicine, Division of Gastroenterology, University of Minnesota, Minneapolis, MN; Minneapolis VA Health Care System, Minneapolis, MN
| | | | | | - Philipp Dahm
- Minneapolis VA Health Care System, Minneapolis, MN; Department of Urology, University of Minnesota, Minneapolis, MN.
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30
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Dunn K, Hamilton Hurwitz H, Toledo JP, Schwaber MJ, Chu M, Chou R, Ford N, Allegranzi B, Baller A. Summary of WHO infection prevention and control guideline for covid-19: striving for evidence based practice in infection prevention and control. BMJ 2024; 385:q645. [PMID: 38782413 PMCID: PMC11116985 DOI: 10.1136/bmj.q645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
| | | | | | - Mitchell J Schwaber
- Israel Ministry of Health, Jerusalem, Israel; Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - May Chu
- Colorado School of Public Health, CO, USA
| | - Roger Chou
- Oregon Health and Science University, Portland, OR, USA
| | - Nathan Ford
- World Health Organization, Geneva, Switzerland
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31
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Queirolo P, Cinquini M, Argenziano G, Bassetto F, Bossi P, Boutros A, Clemente C, de Giorgi V, Del Vecchio M, Patuzzo R, Pennachioli E, Peris K, Quaglino P, Reali A, Zalaudek I, Spagnolo F. Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology. ESMO Open 2024; 9:103005. [PMID: 38688192 PMCID: PMC11067535 DOI: 10.1016/j.esmoop.2024.103005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024] Open
Abstract
Cutaneous squamous cell carcinoma (CSCC) accounts for ∼20%-25% of all skin tumors. Its precise incidence is often challenging to determine due to limited statistics and its incorporation with mucosal forms. While most cases have a favorable prognosis, challenges arise in patients presenting with locally advanced or metastatic forms, mainly appearing in immunocompromised patients, solid organ transplantation recipients, or those facing social difficulties. Traditionally, chemotherapy and targeted therapy were the mainstays for advanced cases, but recent approvals of immunotherapeutic agents like cemiplimab and pembrolizumab have revolutionized treatment options. These guidelines, developed by the Italian Association of Medical Oncologists (AIOM) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, aim to guide clinicians in diagnosing, treating, and monitoring patients with CSCC, covering key aspects from primitive tumors to advanced stages, selected by a panel of experts selected by AIOM and other national scientific societies. The incorporation of these guidelines into clinical practice is expected to enhance patient care and address the evolving landscape of CSCC management.
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Affiliation(s)
- P Queirolo
- Division of Melanoma, Sarcomas and Rare Tumors, IRCCS European Institute of Oncology, Milan
| | - M Cinquini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan
| | - G Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples
| | - F Bassetto
- Clinic of Plastic Surgery, Department of Neuroscience, Padua University Hospital, Padua
| | - P Bossi
- IRCCS Humanitas Research Hospital, Milan
| | - A Boutros
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genoa, Genoa
| | - C Clemente
- Surgical Pathology Department, IRCCS Galeazzi Sant'Ambrogio, Milan
| | - V de Giorgi
- Dermatology Unit, Azienda USL Toscana Centro, Florence; Section of Dermatology, Department of Health Sciences, University of Florence, Florence
| | - M Del Vecchio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan
| | - R Patuzzo
- Fondazione IRCCS Istituto Nazionale Dei Tumori, Melanoma and Sarcoma Unit, Milan
| | - E Pennachioli
- Division of Melanoma, Sarcomas and Rare Tumors, IRCCS European Institute of Oncology, Milan
| | - K Peris
- Dermatology, Department of Medicine and Translational Surgery, Università Cattolica del Sacro Cuore, Rome; Dermatology, Department of Medical and Surgery Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - P Quaglino
- Department of Medical Sciences, Clinic of Dermatology, University of Turin, Turin
| | - A Reali
- Radiation Oncology Department, Michele e Pietro Ferrero Hospital, Verduno
| | - I Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste
| | - F Spagnolo
- Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova; Department of Surgical Sciences and Integrated Diagnostics (DISC), Plastic Surgery Division, University of Genova, Genoa, Italy.
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Ichiuji M, Asakura L, Cain C, Aye N, Kolevska T, Chen D, Brasfield FM, Kotak D. Improving routine use of clinical pathway decision support through integration of an EHR with a clinical library resource designed to provide evidence-based guidance within oncology workflows. BMC Health Serv Res 2024; 24:560. [PMID: 38693492 PMCID: PMC11064314 DOI: 10.1186/s12913-024-11018-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND The rapid evolution, complexity, and specialization of oncology treatment makes it challenging for physicians to provide care based on the latest and best evidence. We hypothesized that physicians would use evidence-based trusted care pathways if they were easy to use and integrated into clinical workflow at the point of care. METHODS Within a large integrated care delivery system, we assembled clinical experts to define and update drug treatment pathways, encoded them as flowcharts in an online library integrated with the electronic medical record, communicated expectations that clinicians would use these pathways for every eligible patient, and combined data from multiple sources to understand usage over time. RESULTS We were able to achieve > 75% utilization of eligible protocols ordered through these pathways within two years, with > 90% of individual oncologists having consulted the pathway at least once, despite no requirements or external incentives associated with pathway usage. Feedback from users contributed to improvements and updates to the guidance. CONCLUSIONS By making our clinical decision support easily accessible and actionable, we find that we have made considerable progress toward our goal of having physicians consult the latest evidence in their treatment decisions.
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Affiliation(s)
- Mary Ichiuji
- The Permanente Federation, 1 Kaiser Plaza, Oakland, CA, 94612, USA
| | - Laura Asakura
- Kaiser Foundation Health Plan & Hospitals, 1 Kaiser Plaza, Oakland, CA, 94612, USA
| | - Carol Cain
- The Permanente Federation, 1 Kaiser Plaza, Oakland, CA, 94612, USA.
| | - Nancy Aye
- Kaiser Foundation Health Plan & Hospitals, 1 Kaiser Plaza, Oakland, CA, 94612, USA
| | - Tatjana Kolevska
- The Permanente Medical Group, 1950 Franklin St, Oakland, CA, 94612, USA
| | - David Chen
- Kaiser Foundation Health Plan & Hospitals, 1 Kaiser Plaza, Oakland, CA, 94612, USA
| | | | - Dinesh Kotak
- The Permanente Medical Group, 1950 Franklin St, Oakland, CA, 94612, USA
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Granholm A, Al Duhailib Z, Alhazzani W, Oczkowski S, Belley-Cote E, Møller MH. GRADE pearls and pitfalls-Part 2: Clinical practice guidelines. Acta Anaesthesiol Scand 2024; 68:593-600. [PMID: 38380849 DOI: 10.1111/aas.14384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is the de facto standard framework for summarising evidence in systematic reviews and developing recommendations in clinical practice guidelines. METHODS We describe how the GRADE approach is used in clinical practice guidelines, including key points and examples. The intended audience of this overview of GRADE is clinicians and researchers who are, or plan to be, involved in the development or assessment of clinical practice guidelines. RESULTS We cover guideline endorsement and adaptation; guideline panels and sponsors; conflicts of interest; guideline questions and outcome prioritisation; systematic review creation, updating and re-use; rating the overall certainty of evidence; development of recommendations and implications; and peer review, publication, implementation and updating of guidelines. CONCLUSIONS This overview aims to help developers, assessors and users of clinical practice guidelines understand how trustworthy, high-quality guidelines are developed using the GRADE approach.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
| | - Zainab Al Duhailib
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Simon Oczkowski
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada
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Oliveira J E Silva L, Bellolio F, Carpenter CR. Clinical relevance rather than evidence existence: The SAEM GRACE pragmatism. Acad Emerg Med 2024; 31:529-532. [PMID: 38594826 DOI: 10.1111/acem.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 04/11/2024]
Affiliation(s)
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Li P, Li Z, Linghu E, Ji J. Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer. Chin Med J (Engl) 2024; 137:887-908. [PMID: 38515297 PMCID: PMC11046028 DOI: 10.1097/cm9.0000000000003101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer. METHODS This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG. RESULTS This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations. CONCLUSIONS This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.
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Affiliation(s)
- Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing 100050, China
| | - Ziyu Li
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100853, China
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
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van den Bergh JP, Geusens P, Appelman-Dijkstra NM, van den Broek HJG, Elders PJM, de Klerk G, van Oostwaard M, Willems HC, Zillikens MC, Lems WF. The Dutch multidisciplinary guideline osteoporosis and fracture prevention, taking a local guideline to the international arena. Arch Osteoporos 2024; 19:23. [PMID: 38564062 PMCID: PMC10987374 DOI: 10.1007/s11657-024-01378-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/26/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND In 2018, a grant was provided for an evidence-based guideline on osteoporosis and fracture prevention based on 10 clinically relevant questions. METHODS A multidisciplinary working group was formed with delegates from Dutch scientific and professional societies, including representatives from the patient's organization and the Dutch Institute for Medical Knowledge. The purpose was to obtain a broad consensus among all participating societies to facilitate the implementation of the updated guideline. RESULTS Novel recommendations in our guideline are as follows: - In patients with an indication for DXA of the lumbar spine and hips, there is also an indication for VFA. - Directly starting with anabolic drugs (teriparatide or romosozumab) in patients with a very high fracture risk; - Directly starting with zoledronic acid in patients 75 years and over with a hip fracture (independent of DXA); - Directly starting with parenteral drugs (denosumab, teriparatide, zoledronic acid) in glucocorticoid-induced osteoporosis with very high fracture risk; - A lifelong fracture risk management, including lifestyle, is indicated from the start of the first treatment. CONCLUSION In our new multidisciplinary guideline osteoporosis and fracture prevention, we developed 5 "relatively new statements" that are all a crucial step forward in the optimization of diagnosis and treatment for fracture prevention. We also developed 5 flowcharts, and we suppose that this may be helpful for individual doctors and their patients in daily practice and may facilitate implementation.
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Affiliation(s)
- J P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands.
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - P Geusens
- Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - N M Appelman-Dijkstra
- Department of Internal Medicine, Division Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - P J M Elders
- Department of General Practice, Amsterdam Public Health Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - G de Klerk
- Department of Surgery, ADRZ, Goes, the Netherlands
| | - M van Oostwaard
- Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - H C Willems
- Department of Internal Medicine and Geriatrics, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - M C Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - W F Lems
- Department of Rheumatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Bognanni A, Fiocchi A, Arasi S, Chu DK, Ansotegui I, Assa'ad AH, Bahna SL, Berni Canani R, Bozzola M, Dahdah L, Dupont C, Dziechciarz P, Ebisawa M, Firmino RT, Chu A, Galli E, Horvath A, Kamenwa R, Lack G, Li H, Martelli A, Nowak-Węgrzyn A, Papadopoulos NG, Pawankar R, Roldan Y, Said M, Sánchez-Borges M, Shamir R, Spergel JM, Szajewska H, Terracciano L, Vandenplas Y, Venter C, Waffenschmidt S, Waserman S, Warner A, Wong GW, Schünemann HJ, Brozek JL. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XII - Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA. World Allergy Organ J 2024; 17:100888. [PMID: 38706757 PMCID: PMC11068951 DOI: 10.1016/j.waojou.2024.100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 05/07/2024] Open
Abstract
Background Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit. Objective These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA. Methods WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders. Results After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.The issued recommendations are labeled as "conditional" following the GRADE approach due to the very low certainty about the health effects based on the available evidence. Conclusions If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers' values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.
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Affiliation(s)
- Antonio Bognanni
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Fiocchi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Derek K. Chu
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | | | - Amal H. Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sami L. Bahna
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Roberto Berni Canani
- Pediatric Allergy Program at the Department of Translational Medical Science, and ImmunoNutritionLab at Ceinge Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Martin Bozzola
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, British Hospital-Perdriel, Buenos Aires, Argentina
| | - Lamia Dahdah
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Christophe Dupont
- Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, France
- Clinique Marcel Sembat, Boulogne-Billancourt, France
| | - Piotr Dziechciarz
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Ramon T. Firmino
- Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil
| | - Alexandro Chu
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | - Elena Galli
- Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy
| | - Andrea Horvath
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Rose Kamenwa
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Gideon Lack
- King's College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Pediatric Allergy, St Thomas' Hospital, London, UK
| | - Haiqi Li
- Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China
| | - Alberto Martelli
- Member of Italian Society of Allergy and Pediatric Immunology (SIAIP), Italy
| | - Anna Nowak-Węgrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maria Said
- Allergy & Anaphylaxis Australia, Castle Hill, New South Wales, Australia
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad and Clínica El Avila, Caracas, Venezuela
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Luigi Terracciano
- Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy
| | - Yvan Vandenplas
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Siw Waffenschmidt
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Susan Waserman
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | | | - Gary W.K. Wong
- Department of Paediatrics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Medicine, Division of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jan L. Brozek
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
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Krishnan JA, Buhl R. As-needed ICS/formoterol or as-needed SABA in mild asthma? Eur Respir J 2024; 63:2302308. [PMID: 38575166 DOI: 10.1183/13993003.02308-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 04/06/2024]
Affiliation(s)
| | - Roland Buhl
- Johannes Gutenberg University of Mainz, Mainz, Germany
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Apeldoorn AT, Swart NM, Conijn D, Meerhoff GA, Ostelo RW. Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF). Eur J Phys Rehabil Med 2024; 60:292-318. [PMID: 38407016 PMCID: PMC11112513 DOI: 10.23736/s1973-9087.24.08352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines. AIM To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists. DESIGN Clinical practice guideline. SETTING Inpatient and outpatient. POPULATION Adults with LBP and/or LRS. METHODS Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase. RESULTS The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment. CONCLUSIONS An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises. CLINICAL REHABILITATION IMPACT This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.
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Affiliation(s)
- Adri T Apeldoorn
- Department of Rehabilitation, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands -
| | - Nynke M Swart
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Daniëlle Conijn
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Guus A Meerhoff
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Raymond W Ostelo
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Free University, Amsterdam, the Netherlands
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Raspovic KM, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Wukich DK. Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3653. [PMID: 37179484 DOI: 10.1002/dmrr.3653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin. METHODS We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. RESULTS We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. CONCLUSIONS There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.
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Affiliation(s)
- Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F. Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3786. [PMID: 38507616 DOI: 10.1002/dmrr.3786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND It is critical that interventions used to enhance the healing of chronic foot ulcers in diabetes are backed by high-quality evidence and cost-effectiveness. In previous years, the systematic review accompanying guidelines published by the International Working Group of the Diabetic Foot performed 4-yearly updates of previous searches, including trials of prospective, cross-sectional and case-control design. AIMS Due to a need to re-evaluate older studies against newer standards of reporting and assessment of risk of bias, we performed a whole new search from conception, but limiting studies to randomised control trials only. MATERIALS AND METHODS For this systematic review, we searched PubMed, Scopus and Web of Science databases for published studies on randomised control trials of interventions to enhance healing of diabetes-related foot ulcers. We only included trials comparing interventions to standard of care. Two independent reviewers selected articles for inclusion and assessed relevant outcomes as well as methodological quality. RESULTS The literature search identified 22,250 articles, of which 262 were selected for full text review across 10 categories of interventions. Overall, the certainty of evidence for a majority of wound healing interventions was low or very low, with moderate evidence existing for two interventions (sucrose-octasulfate and leucocyte, platelet and fibrin patch) and low quality evidence for a further four (hyperbaric oxygen, topical oxygen, placental derived products and negative pressure wound therapy). The majority of interventions had insufficient evidence. CONCLUSION Overall, the evidence to support any other intervention to enhance wound healing is lacking and further high-quality randomised control trials are encouraged.
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Affiliation(s)
- Pam Chen
- Joondalup Health Campus, Ramsay Healthcare Australia, Joondalup, Western Australia, Australia
- Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Nalini Campillo Vilorio
- Department of Diabetology, Diabetic Foot Unit, Plaza de la Salud General Hospital, Santo Domingo, Dominican Republic
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Ralf Lobmann
- Clinic for Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - John Steinberg
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Prash Vas
- King's College Hospital NHS Foundation Trust, London, UK
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Prof M Viswanathan Diabetes Research Center, Chennai, India
| | - Stephanie Wu
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Herman D, Ghazipura M, Barnes H, Macrea M, Knight SL, Silver RM, Montesi SB, Raghu G, Hossain T. Nintedanib Therapy Alone and Combined with Mycophenolate in Patients with Systemic Sclerosis-associated Interstitial Lung Disease: Systematic Reviews and Meta-analysis. Ann Am Thorac Soc 2024; 21:474-485. [PMID: 37773000 DOI: 10.1513/annalsats.202301-081oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/18/2023] [Indexed: 09/30/2023] Open
Abstract
Background: The American Thoracic Society convened an international multidisciplinary panel to develop clinical practice guidelines for the treatment of systemic sclerosis-associated interstitial lung disease (SSc-ILD). Objective: To conduct a systematic review and evaluate the literature to determine whether patients with SSc-ILD should be treated with nintedanib alone or with the combination of nintedanib plus mycophenolate. Data Sources: Literature searches were conducted across MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases through June 2022 for studies using nintedanib or nintedanib plus mycophenolate to treat patients with SSc-ILD. Data Extraction: Mortality, disease progression, quality of life, and adverse event data were extracted, and meta-analysis was performed when possible. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group method was used to assess the quality of evidence. Synthesis: For nintedanib therapy alone, the systematic review included three total studies and revealed that disease progression was less in the nintedanib arm (the annual rate of decline in forced vital capacity [FVC] was 44.5 ml less, the absolute change from baseline was 46.4 ml less, and FVC% predicted was 1.2% less in the nintedanib arm) compared with placebo. However, gastrointestinal side effects and treatment discontinuation were double in the nintedanib arm compared with placebo. For combination therapy, the systematic review also included three total studies and revealed that changes in the annual rate of decline in FVC favored combination therapy over placebo (mean difference, 79.1 ml). Combination therapy was, however, associated with increased gastrointestinal adverse effects compared with placebo. The quality of evidence for all outcomes was very low as per GRADE. Conclusions: The use of nintedanib alone and in combination with mycophenolate in patients with SSc-ILD is associated with a significant reduction in disease progression compared with placebo but at the cost of increased gastrointestinal side effects and treatment discontinuation. The quality of evidence is very low.
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Affiliation(s)
- Derrick Herman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Marya Ghazipura
- ZS Associates, Global Health Economics and Outcomes Research, New York, New York
- Division of Epidemiology and
- Division of Biostatistics, Department of Population Health and
| | - Hayley Barnes
- Central Clinical School and
- Centre for Occupational and Environmental Health, Monash University, Melbourne, Australia
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - Madalina Macrea
- Division of Pulmonary and Sleep Medicine, Salem Veterans Affairs Medical Center, Salem, Virginia
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Shandra L Knight
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard M Silver
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Ganesh Raghu
- Center for Interstitial Lung Diseases, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Tanzib Hossain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, New York
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Guidelines on the classification of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3648. [PMID: 37179483 DOI: 10.1002/dmrr.3648] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND This publication represents a scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. The guidelines are based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the GRADE methodology. METHODS First, we have developed a list of classification systems considered as being potentially adequate for use in a clinical setting, through the summary of judgements for diagnostic tests, focussing on the usability, accuracy and reliability of each system to predict ulcer-related complications as well as use of resources. Second, we have determined, following group debate and consensus, which of them should be used in specific clinical scenarios. Following this process, in a person with diabetes and a foot ulcer we recommend: (a) for communication among healthcare professionals: to use the SINBAD (Site, Ischaemia, Bacterial infection, Area and Depth) system (first option) or consider using WIfI (Wound, Ischaemia, foot Infection) system (alternative option, when the required equipment and level of expertise is available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (b) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (c) for characterising a person with an infected ulcer: the use of the IDSA/IWGDF classification (first option) or consider using the WIfI system (alternative option, when the required equipment and level of expertise is available and it is considered as feasible); (d) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (e) for the audit of outcome(s) of populations: the use of the SINBAD score. CONCLUSIONS For all recommendations made using GRADE, the certainty of evidence was judged, at best, as being low. Nevertheless, based on the rational application of current data this approach allowed the proposal of recommendations, which are likely to have clinical utility.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health-Lisbon, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, Texas, USA
| | | | - Frances Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Tetreault LA, Skelly AC, Alvi MA, Kwon BK, Evaniew N, Fehlings MG. An Overview of the Methodology Used to Develop Clinical Practice Guidelines for the Management of Acute and Intraoperative Spinal Cord Injury. Global Spine J 2024; 14:25S-37S. [PMID: 38526928 DOI: 10.1177/21925682231215266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN An overview of the methods used to develop clinical practice guidelines (CPGs). OBJECTIVES Acute spinal cord injury (SCI) and intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. To date, there are several studies that have discussed the diagnostic and management strategies for both SCI and ISCI. CPGs in SCI help to distill and translate the current evidence into actionable recommendations, standardize care across centers, optimize patient outcomes, and reduce costs and unnecessary interventions. Furthermore, they can be used by patients to assist in making decisions about certain treatments and by policy makers to inform allocation of resources. The objective of this article is to summarize the methods used to develop CPGs for the timing of surgery and hemodynamic management of acute SCI, as well as the identification and treatment of ISCI. METHODS The CPGs were developed using standards established by the Institute of Medicine (now the National Academy of Medicine), the Guideline International Network and several other organizations. Systematic reviews were conducted according to accepted methodological standards (eg, Institute of Medicine, Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute) in order to summarize the current body of evidence and inform the guideline development process. Protocols for each guideline were created. A multidisciplinary guideline development group (GDG) was formed that included individuals living with SCI as well as clinicians from the broad range of specialties that encounter patients with SCI: spine or trauma surgeons, critical care physicians, rehabilitation specialists, neurologists, anesthesiologists and other healthcare professionals. Individuals living with SCI were also included in the GDG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to rate the certainty of the evidence for each critical outcome. The "evidence to recommendation" framework was then used to translate the evidence obtained from the systematic review to an actionable recommendation. This framework provides structure when assessing the body of evidence and considers several additional factors when rating the strength of the recommendation, including the magnitude of benefits and harms, patient preferences, resource use, health equities, acceptability and feasibility. Finally, the CPGs were appraised both internally and externally. RESULTS The results of the CPGs for SCI are provided in separate articles in this focus issue. CONCLUSIONS Development of these CPGs for SCI followed the methodology proposed by the Institute of Medicine the Guideline International Network and the GRADE Working Group. It is anticipated that these CPGs will assist clinicians implement the best evidence into practice and facilitate shared-decision making with patients.
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Affiliation(s)
| | | | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Bus SA, Monteiro-Soares M, Game F, van Netten JJ, Apelqvist J, Fitridge R, Senneville E, Schaper NC. Standards for the development and methodology of the 2023 IWGDF guidelines. Diabetes Metab Res Rev 2024; 40:e3656. [PMID: 37179482 DOI: 10.1002/dmrr.3656] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
AIMS Diabetes-related foot disease is a major source of patient burden and societal costs. Investing in evidence-based international guidelines on diabetes-related foot disease is important to reduce this burden and costs, provided the guidelines are focused on outcomes important to key stakeholders and are evidence-based and properly implemented. MATERIALS AND METHODS The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2023 updates were made using the Grading of Recommendations Assessment Development and Evaluation evidence-to-decision framework. This concerns formulating relevant clinical questions and important outcomes, conducting systematic reviews of the literature and meta-analyses where appropriate, completing summary of judgement tables, and writing recommendations that are specific, unambiguous and actionable, along with their transparent rationale. RESULTS We herein describe the development of the 2023 IWGDF Guidelines on the prevention and management of diabetes-related foot disease, which consists of seven chapters, each prepared by a separate working group of international experts. These chapters provide guidelines related to diabetes-related foot disease on prevention; classification of diabetes-related foot ulcer, offloading, peripheral artery disease, infection, wound healing interventions, and active Charcot neuro-osteoarthropathy. Based on these seven guidelines, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. CONCLUSIONS We believe that the adoption and implementation of the 2023 IWGDF guidelines by healthcare providers, public health agencies, and policymakers will improve the prevention and management of diabetes-related foot disease, and subsequently reduce the worldwide patient and societal burden caused by this disease.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing, France
- Univ-lille, Lille, France
| | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3647. [PMID: 37226568 DOI: 10.1002/dmrr.3647] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/26/2023]
Abstract
AIMS Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. RESULTS For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. CONCLUSION These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Science, Program Rehabilitation & Development, Amsterdam, Netherlands
| | - David G Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - Ryan T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, North Chicago, Illinois, USA
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Gustav Jarl
- Faculty of Medicine and Health, Department of Prosthetics and Orthotics, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - Klaus Kirketerp-Moller
- Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark
- Steno Diabetes Center, Copenhagen, Denmark
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
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Fehlings MG, Tetreault LA, Hachem L, Evaniew N, Ganau M, McKenna SL, Neal CJ, Nagoshi N, Rahimi-Movaghar V, Aarabi B, Hofstetter CP, Wengel VT, Nakashima H, Martin AR, Kirshblum S, Rodrigues Pinto R, Marco RAW, Wilson JR, Kahn DE, Newcombe VFJ, Zipser CM, Douglas S, Kurpad SN, Lu Y, Saigal R, Samadani U, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery. Global Spine J 2024; 14:174S-186S. [PMID: 38526922 DOI: 10.1177/21925682231181883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Clinical practice guideline development. OBJECTIVES Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.
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Affiliation(s)
- Michael G Fehlings
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Laureen Hachem
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- Department of Surgery, Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mario Ganau
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Chris J Neal
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Valerie Ter Wengel
- Department of Neurosurgery, Amsterdam UMC VUMC Site, Amsterdam, Netherlands
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Allan R Martin
- Department of Neurological Surgery, University of California-Davis, Sacramento, CA, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ricardo Rodrigues Pinto
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Hospital CUF Trindade, Porto, Portugal
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - David E Kahn
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia and PACE, University of Cambridge, Cambridge, UK
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yi Lu
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Uzma Samadani
- Department of Surgery, Minneapolis Veterans Affairs, Minneapolis, MN, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev 2024; 40:e3687. [PMID: 37779323 DOI: 10.1002/dmrr.3687] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 10/03/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, the Netherlands
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Wukich DK, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Raspovic KM. Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res Rev 2024; 40:e3646. [PMID: 37218537 DOI: 10.1002/dmrr.3646] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3644. [PMID: 37232034 DOI: 10.1002/dmrr.3644] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023]
Abstract
AIMS Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders. RESULTS From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions. CONCLUSIONS These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.
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Affiliation(s)
- Pam Chen
- Joondalup Health Campus, Ramsay Healthcare Australia, Joondalup, Western Australia, Australia
- Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Nalini Campillo Vilorio
- Department of Diabetology, Diabetic Foot Unit, Plaza de la Salud General Hospital, Santo Domingo, Dominican Republic
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Ralf Lobmann
- Clinic for Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Stuttgart, Germany
| | - Caroline McIntosh
- Podiatric Medicine, School of Health Sciences, University of Galway, Galway, Ireland
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - John Steinberg
- Georgetown University School of Medicine, Georgetown, Washington DC, USA
| | - Prash Vas
- King's College Hospital NHS Foundation Trust, London, UK
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Prof M Viswanathan Diabetes Research Center, Chennai, India
| | - Stephanie Wu
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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