Management paradigms for chronic rhinosinusitis in individuals with asthma: An evidence-based review with recommendations

BACKGROUND

Despite the significant morbidity associated with chronic rhinosinusitis (CRS) in individuals with asthma (CRSwA), there is a paucity of codified, evidence-based management strategies for CRS in this population.

METHODS

Using PubMed, Embase, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. A total of 5903 articles were screened, and 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded and benefit-harm assessments, as well as value judgment and recommendations, were provided RESULTS: Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate to strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient to low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.

CONCLUSION

Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional nonbiologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who have CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status.

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.

AIMS

To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field.

METHODS

Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected.

RESULTS

While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts.

CONCLUSION

Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.

Effects of Air Pollution on the Health of Older Adults during Physical Activities: Mapping Review

Atmospheric pollutants present environmental threats to health and have been investigated in different environments, such as highways, squares, parks, and gyms. These environments are frequented by older adults, who are considered fragile to the harmful impacts of pollution present in the air. The aim was to analyze the state of the art on the effects of air pollution on the health of older adults during physical activities (PAs) through a mapping review. The search was performed in PubMed, Web of Science, Scopus, and Cinahl databases until June 2022. Of the 10,109 studies initially identified, 58 met the inclusion criteria. The most investigated health outcome was cardiovascular disease, followed by respiratory outcomes. Particulate matter (PM2.5 and PM10), nitrogen dioxide (NO2), and ozone (O3) were the most investigated pollutants. Of the 75 health outcomes investigated, in 29, air pollution had harmful effects on the health of the older adults during the practice of PA, more frequently in cardiovascular diseases. In 25 outcomes, the beneficial effects of PA to the health of the older adults remained, despite exposure to high and low concentrations of pollutants, most often in terms of mental disorders. We conclude that poor air quality is a harmful factor for the health of older adults during the practice of PAs, more frequently in cardiovascular and respiratory diseases. On the other hand, for mental-health-related outcomes (depression and cognition), in most studies, the beneficial effects of PA in older adults were maintained, even after exposure to pollutants.

Breast cancer-related lymphoedema and resistance exercise: An evidence-based review of guidelines, consensus statements and systematic reviews

AIMS AND OBJECTIVES

Breast cancer-related lymphoedema (BCRL) is a side effect of cancer treatment and can be alleviated by resistance exercise. This systematic, evidence-based review examined the existing best evidence on resistance exercise for BCRL to accurately describe the current status of the field and offer recommendations for clinicians.

METHODS

This review adheres to the PRISMA guidelines. Clinical practice guidelines, consensus documents, systematic reviews and other related evidence-based resources about resistance exercise for BCRL were retrieved through the English databases and guideline websites. The publication data limit was set to December 2020. The following search terms were used: 'breast cancer/breast neoplasm/breast carcinoma/breast tumor/breast malignancy, lymphedema/swelling/edema/lymphoedema, resistance/weight/strength training, best practice/clinical practice/guideline/consensus documents'. The quality of the included studies was evaluated by two authors independently using AGREE II and AMSTAR II tools. Evidence-based recommendations on resistance exercise relevant for BCRL were synthesised and categorised.

RESULTS

Twenty two articles (seven guidelines, four consensus documents and eleven systematic reviews) were included. The overall quality of the eleven eligible guidelines and consensus documents was moderate to high according to the AGREE II criteria. The quality of the eleven systematic reviews was critically low to high according to the AMSTAR criteria. Six clinical topics involving 43 recommendations were identified. Recommendations were categorised by safety of resistance training, effectiveness of resistance training, evaluation prior to resistance exercise, resistance exercise prescription, resistance training outcome index and points for attention.

CONCLUSIONS

This study summarises 43 recommendations for resistance training for BCRL and provides guidance for clinicians. Based on randomised trials and systematic reviews published in recent years, there is an urgent need to update the guidelines and consensus documents in terms of topics, for example effectiveness of resistance training and resistance training outcome index.

Evidence-based review of the effects of nutritional supplementation for pressure ulcer prevention

The objective of this evidence-based review was to explore whether the evidence supports the use of nutritional supplements in pressure ulcer (PU) prevention strategies. Several electronic databases, including Ovid MEDLINE (1946 to May week 32 019), Ovid EMBASE (1947 to May 28, 2019), EBSCO CINAHL (until June 13, 2019), Scopus (until July 9, 2019), and the Web of Science (until June 13, 2019) were searched. No limitation was placed on the year of publication. Studies considered for inclusion were those with adult populations, and only English language texts with available full text were reviewed. AMSTAR (a measurement tool to assess systematic reviews) was used to evaluate the quality of the studies included in the systematic review. The Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence was used to assess the level of evidence. Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) was used to assess guideline article, and Appraisal tool for Cross-Sectional Studies (AXIS) was also used for cross-sectional studies. The search identified 1761 studies. After the application of inclusion and exclusion criteria, 24 studies were retained of various designs, including 10 systematic reviews, five clinical reviews, three randomised controlled trials, two observational studies, one quasi-experimental study, one cross-sectional study, one cohort study, and one Clinical Guideline. Two were rated as high-quality reviews, 14 were rated as moderate-quality reviews, five were rated as low-quality reviews, and three were rated as critically low-quality reviews. The majority of the reviewed studies were of low-to-moderate quality because of biases in the study design and incomplete data reporting, which did not fulfil the reporting criteria of the appraisal tools. However, the majority of the studies showed a reduction in PU incidence after nutritional supplement though not significant. Whether the use of pharmacological appraisal tools to assess non-pharmacological studies is appropriate is unclear. Regardless of the low-to-moderate quality of the studies in this review, nutritional supplements appear to play a role in PU prevention.

Individual factors associated with baseball pitching performance: scoping review

Background

Ball velocity, accuracy and game statistics represent three methods used to measure pitching performance. However, individual determinants of pitching performance are more elusive.

Objectives

The aims of this study were to classify the performance factors associated with baseball pitchers, to identify the methods used to quantify their abilities through all features of the game and to document relationships between performance factors and indicators.

Design

Scoping review.

Data sources

Electronic searches of MEDLINE, Academic Search Complete, CINAHL, SportDiscus, PubMed, PsycINFO, Cochrane and of grey literature were undertaken from inception to January 2019.

Eligibility criteria for selecting studies

Cross-sectional studies that investigated the relationship between performance indicators and individual performance factors in healthy baseball pitchers were selected.

Results

Thirty-four cross-sectional studies investigating individual potential factors of pitching performance met the inclusion criteria. The primary performance factors investigated were kinematic, kinetic, timing outcomes, personal characteristics, physical tests and range of motion. Shoulder horizontal adduction (SHA), upper torso forward flexion, maximal shoulder external rotation, upper torso rotation angle, upper torso lateral flexion, lead knee flexion (LKF) and forward trunk tilt (FTT) were identified as key kinematic features associated with increased ball velocity. Shoulder proximal force and peak elbow proximal forces were associated with greater ball velocity. Individual performances in jumping tests and body weight (BW) are also associated with pitching performance.

Summary/conclusion

Based on studies presenting low and moderate risk of bias, we conclude that BW, age and kinematics, such as FTT, LKF, SHA and lateral trunk tilt, are associated with pitching performance.

Efficacy of Pharmacological Therapies for Adhesive Capsulitis of the Shoulder: A Systematic Review and Network Meta-analysis

BACKGROUND

Several pharmacological interventions are used for the management of adhesive capsulitis of the shoulder, although the optimal treatment has yet to be defined.

PURPOSE

To conduct a network meta-analysis to compare the effects of different pharmacological interventions for adhesive capsulitis, administered either alone or after distension of the shoulder capsule.

STUDY DESIGN

Network meta-analysis.

METHODS

The authors searched Scopus, PubMed, and the Cochrane Central Register of Controlled Trials up to April 22, 2018, for completed studies. They enrolled trials that assessed the results of different pharmacological treatments for the primary management of adhesive capsulitis. The primary outcome was pain relief as measured by self-administered questionnaires. The secondary outcome included the assessment of composite instruments that evaluated, at a minimum, pain and function. The authors clinically interpreted the results after back-transforming the standardized mean differences into mean differences in simple instruments and assessed the quality of the source studies using the Cochrane "risk of bias" tool.

RESULTS

The authors considered 30 trials with a total of 2010 participants in this systematic review. For pain relief, there was a significant difference in favor of intra-articular corticosteroids and distension of the shoulder capsule with steroids as compared with control in the short term (mean difference in visual analog scale (VAS): -1.4 [95% CI, -2.5 to -0.4] and -1.7 [95% CI, -3.2 to -0.1], respectively). Furthermore, rotator-interval injections were found to be superior to placebo (mean difference in VAS: -7.2; 95% CI, -10.1 to -4.4), although the intervention was considered in only 1 trial. Finally, there was a statistically significant difference in favor of multiple-site corticosteroid injections compared to placebo in both the short- (mean difference in Shoulder Pain and Disability Index [SPADI]: -86.7; 95% CI, -133.6 to -40) and intermediate-term assessment (mean difference in SPADI: -102.9; 95% CI, -163.9 to -41.8).

CONCLUSION

Intra-articular corticosteroid intervention, administered either alone or after distension of the shoulder capsule, provided clinically meaningful improvements in the short term. Likewise, rotator-interval corticosteroid injections yielded promising results in terms of pain relief. However, these short-term benefits of steroids dissipated over time. Multiple-site corticosteroid injections showed clinical advantage over placebo for short- and intermediate-term composite outcome assessments.

Cardiovascular Health of Retired Field-Based Athletes: A Systematic Review and Meta-analysis

Background:

Retirement from elite sport participation is associated with decreased physical activity, depression, obesity, and ischemic heart disease. Although engagement in physical activity through sport is recognized as cardioprotective, an estimated one-quarter of deaths in American football players are associated with cardiovascular disease (CVD), predominately in players classified as obese.

Purpose:

To systematically investigate the cardiovascular health profile of retired field-based athletes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and preregistered with PROSPERO. Four databases (PubMed, CINAHL, Embase, and Web of Science) were systematically searched from inception to October 2018 using MeSH terms and keywords. Inclusion criteria were retired field-based athletes, age >18 years, and at least 1 CVD risk factor according to the European Society of Cardiology and the American Heart Association. Review articles were not included. Control groups were not required for inclusion, but when available, an analysis was included. Eligible articles were extracted using Covidence. Methodological quality was assessed independently by 2 reviewers using the AXIS tool. The accuracy of individual study estimates was analyzed using a random-effects meta-analysis.

Results:

This review yielded 13 studies. A total of 4350 male retired field-based athletes from 2 sports (football and soccer; age range, 42.2-66 years) were included. Eight studies compared retired athletes with control groups. Retired athletes had elevated systolic blood pressure in 4 of 6 studies; approximately 50% of studies found greater high-density lipoprotein, approximately 80% found lower triglyceride levels, and all studies found greater low-density lipoprotein for retired athletes compared with controls. The prevalence and severity of coronary artery calcium and carotid artery plaque were similar to controls. Retired linemen had double the prevalence of cardiometabolic syndrome compared with nonlinemen.

Conclusion:

The overall findings were mixed. Inconsistencies in the reporting of CVD risk factors and methodological biases reduced the study quality. Retired athletes had a comparable CVD risk profile with the general population. Retired athletes with an elevated body mass index had an increased prevalence and severity of risk factors. Significant gaps remain in understanding the long-term cardiovascular effects of elite athleticism.

Cognition and return to work after mild/moderate traumatic brain injury: A systematic review

BACKGROUND

Approximately two percent of the United States population are traumatic brain injury (TBI) survivors. The unemployment rate among them is substantial. Cognitive skills are essential to perform any job.

OBJECTIVE

We analyzed the literature on cognitive rehabilitation (CR) related to mild/moderate TBI to learn the influence of cognition on return to work (RTW) post TBI.

METHODS

We conducted a systematic review of the studies on CR related to RTW post TBI that were published between 2000 and 2015.

RESULTS

We critically reviewed 30 studies that met the inclusion criteria. Ten studies highlighted cognition as a predictor variable, seven studies demonstrated support for cognitive testing in RTW assessments, and 13 studies showed the efficacy of CR in facilitating RTW post TBI.

CONCLUSION

Cognition plays a significant role in predicting and facilitating RTW in patients with TBI.

Clinical use of lenvatinib in combination with everolimus for the treatment of advanced renal cell carcinoma

Introduction

Renal cell carcinoma (RCC) represents 2%–3% of all cancers in adults, and its pathogenesis is mainly related to altered cellular response to hypoxia. Lenvatinib, a novel multitarget tyrosine kinase inhibitor (TKI), represents a therapeutic option, in combination with mammalian target of rapamycin (mTOR) inhibitor everolimus, for the treatment of metastatic RCC (mRCC).

Aim

The objective of this article is to review the evidence about the treatment of mRCC with combination of lenvatinib plus everolimus.

Evidence review

Phase I studies supported clinical activity of lenvatinib in mRCC. A randomized, Phase II, open-label, multicenter trial demonstrated the clinical efficacy of combination treatment with lenvatinib plus everolimus in patients with progressive mRCC after prior therapy with TKI. Median progression-free survival was improved by 9 months with the combination therapy compared to the single-agent everolimus, with an overall response rate of 43% for the experimental regimen. Lenvatinib plus everolimus appeared to be slightly less toxic than single-agent lenvatinib and more toxic than single-agent everolimus; grade 3–4 adverse events occurred in 71% of patients. Currently, lenvatinib plus everolimus has US Food and Drug Administration approval for its use in mRCC after failure of previous treatment with TKI.

Conclusion

The combination therapy with lenvatinib plus everolimus might be a promising choice for second-line treatment of mRCC patients. Based on the results of the Phase II trial, it is possible to speculate that the combination therapy could be appropriate for patients with high disease burden or strongly symptomatic patients.

Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review

INTRODUCTION

Hyperkalemia is a serious medical condition that often manifests in patients with chronic kidney disease and heart failure. Renin-angiotensin-aldosterone system inhibitors are known to improve outcomes in these disease states but can also cause drug-induced hyperkalemia. New therapeutic options exist for managing hyperkalemia in these patients which warrant evidence-based evaluation.

AIM

The objective of this article was to review the efficacy and safety evidence for patiromer, sodium zirconium cyclosilicate (ZS9), and sodium polystyrene sulfonate (SPS) for the treatment of hyperkalemia.

EVIDENCE REVIEW

Current treatment options to enhance potassium excretion are SPS and loop diuretics, which are complicated by ambiguous efficacy and known toxicities. Patiromer and ZS9 are new agents designed to address this treatment gap. Both unabsorbable compounds bind potassium in the gastrointestinal (GI) tract to facilitate fecal excretion. The capacity to bind other medications in the GI tract infers high drug-drug interaction potential, which has been demonstrated with patiromer but not yet investigated with ZS9 or SPS. Phase II and III clinical trials of patiromer and ZS9 demonstrated clear evidence of a dose-dependent potassium-lowering effect and the ability to initiate, maintain, or titrate renin-angiotensin-aldosterone system inhibitors. There is limited evidence base for SPS: two small clinical trials indicated potassium reduction in chronic hyperkalemia. All agents may cause adverse GI effects, although they are less frequent with ZS9. Concerns remain for SPS to cause rare GI damage. Electrolyte abnormalities occurred with patiromer and SPS, whereas urinary tract infections, edema, and corrected QT-interval prolongations were reported with ZS9.

CONCLUSION

Patiromer and ZS9 have improved upon the age-old standard SPS for the treatment of hyperkalemia. Additional research should focus on drug-drug interactions in patients on multiple medications, incidence of rare adverse events, and use in high-risk populations.

Canagliflozin in the treatment of type 2 diabetes: an evidence-based review of its place in therapy

INTRODUCTION

Deciding on an optimal medication choice for type 2 diabetes is often challenging, due to the increasing number of treatment options. Canagliflozin is a novel glucose-lowering agent belonging to sodium-glucose co-transporter 2 (SGLT2) inhibitors.

AIM

The aim of this study was to examine and summarize the evidence based on the efficacy, safety, and cost-effectiveness of canagliflozin for type 2 diabetes.

EVIDENCE REVIEW

Compared to placebo, canagliflozin 100 and 300 mg lower glycated hemoglobin (HbA1c) by ~0.6%-0.8%, respectively. Canagliflozin appears to be slightly more effective than dipeptidyl peptidase-4 (DPP-4) inhibitors in reducing HbA1c. It also has a favorable effect on body weight and blood pressure, both versus placebo and most active comparators. However, treatment with canagliflozin is associated with increased incidence of genital tract infections and osmotic diuresis-related adverse events. Based on short-term data, canagliflozin is not associated with increased risk for all-cause mortality and cardiovascular outcomes. Economic evaluation studies from various countries indicate that canagliflozin is a cost-effective option in dual- or triple-agent regimens.

PLACE IN THERAPY

As monotherapy, canagliflozin could be used in patients for whom metformin is contraindicated or not tolerated. For patients on background treatment with metformin, canagliflozin appears to be superior to sulfonylureas with respect to body weight, blood pressure and risk for hypoglycemia, and to DPP-4 inhibitors in terms of lowering HbA1c, body weight, and blood pressure. Canagliflozin also seems to be cost-effective compared with sulfonylureas and DPP-4 inhibitors as add-on to metformin monotherapy, and compared with DPP-4 inhibitors as add-on to metformin and sulfonylurea.

CONCLUSION

Current evidence on intermediate efficacy outcomes, short-term safety and cost-effectiveness support the use of canagliflozin in patients on background treatment with metformin. Robust long-term data regarding the effect of canagliflozin on cardiovascular endpoints will be available upon completion of the Canagliflozin Cardiovascular Assessment Study (CANVAS) trial.

Children's exposure to intimate partner violence: an overview

Children's exposure to intimate partner violence (IPV) is associated with significant emotional impairment and other harmful effects. It is increasingly recognized as a type of child maltreatment, with outcomes similar to other types of abuse and neglect. Children can experience harm from exposure to IPV, even when not directly involved in, or a witness to, the violence between caregivers. This review, based on a synthesis of best available evidence, addresses the epidemiology of children's exposure to IPV, including prevalence, risk and protective factors, and associated impairment, as well as strategies for identification, and interventions for prevention of exposure and impairment. Strategies for ensuring children's safety are also discussed. The article concludes with guidance specific to mental health clinicians.

Everolimus in the management of metastatic renal cell carcinoma: an evidence-based review of its place in therapy

Introduction

Renal cell carcinoma (RCC) is the most common type of kidney cancer in adults, and its pathogenesis is strictly related to altered cellular response to hypoxia, in which mTOR signaling pathway is implicated. Everolimus, an mTOR serine/threonine kinase inhibitor, represents a therapeutic option for the treatment of advanced RCC.

Aim

The objective of this article is to review the evidence for the treatment of metastatic RCC with everolimus.

Evidence review

Everolimus was approved for second- and third-line therapy in patients with advanced RCC according to the results of a Phase III pivotal trial that demonstrated a benefit in median progression-free survival of ~2 months compared to placebo after failure of previous lines of therapy, of which at least one was an anti-VEGFR tyrosine kinase inhibitor (TKI). The role of this drug in first-line setting has been investigated in Phase II trials, with no significant clinical benefit, even in combination with bevacizumab. Everolimus activity in non-clear cell RCC is supported by two randomized Phase II trials that confirmed the benefit in second-line setting but not in first line. Recently, two randomized Phase III trials (METEOR and CheckMate 025) demonstrated the inferiority of everolimus in second-line setting compared to the TKI cabozantinib and to the immune checkpoint inhibitor nivolumab, respectively. Moreover, a recent Phase II study demonstrated a significant benefit for the second-line combination treatment with everolimus plus lenvatinib (a novel TKI) in terms of progression-free survival and overall survival compared to the single-agent everolimus. Basing on preclinical data, the main downstream effectors of mTOR cascade, S6RP and its phosphorylated form, could be good predictive biomarkers of response to everolimus. The safety profile of the drug is favorable, with a good cost-effectiveness compared to second-line sorafenib or axitinib, and no significant impact on the quality of life of treated patients has been found.

Conclusion

Everolimus still represents a current standard of treatment for RCC progressive to previous treatment lines with VEGFR-TKI. The evidence about two new molecules, cabozantinib and nivolumab, successfully tested head-to-head with everolimus in recently published Phase III trials, will determine the shift of everolimus to the third-line setting and subsequent lines of treatment.

Transarterial chemoembolization for hepatocellular carcinoma: an evidence-based review of its place in therapy

Transarterial chemoembolization (TACE) is the standard treatment for patients with Barcelona Clinic Liver Cancer-intermediate stage hepatocellular carcinoma (HCC). The concept of drug-eluting bead TACE builds on the rationale of intratumoral drug delivery, and drug-eluting bead TACE has been shown to provide consistent and reliable results and to significantly diminish systemic drug exposure, liver toxicity, and drug-related adverse events as compared with conventional TACE. Based on the belief that combinations of TACE and other local or systemic therapies have several theoretical advantages, many clinical trials have been conducted to evaluate the effectiveness of TACE in combination with local treatment such as radiofrequency ablation or radiotherapy, and systemic therapy such as sorafenib or another molecular therapy. TACE has also been used as a preoperative adjuvant chemotherapy in patients with HCC to improve survival and as a bridging therapy before liver transplantation to downstage HCC. In the present evidence-based review, the authors summarize the current status of these transcatheter arterial embolic therapies in HCC.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Use and applications of systematic reviews in public health nutrition

Decisions related to a spectrum of nutrition-related public health and clinical concerns must consider many factors and are best informed by evaluating the totality and quality of the evidence. Systematic review (SR) is a structured process to evaluate, compare, and synthesize relevant evidence for the SR-specific question(s). Applications of SR are exemplified here through the discussion of four case studies: research agendas, nutrient reference intakes, dietary guidance, and practice guidelines. Concerns that SR cannot be effectively applied to nutrition evidence because of the lack of an unexposed comparator and the complex homeostasis in nutrition are discussed. Central to understanding the applicability of SR is its flexibility in defining key inclusion criteria and rigorous elements as appropriate for the SR-specific question(s). Through the reduction of bias and random error by explicit, reproducible, comprehensive, and rigorous examination of all of the evidence, SR informs the scientific judgment needed for sound evidence-based public health nutrition.

Predictive and prognostic biomarkers with therapeutic targets in breast, colorectal, and non-small cell lung cancers: a systemic review of current development, evidence, and recommendation

Appropriate evidence-based roles of prognostic and predictive biomarkers of known therapeutic targets in breast, colorectal, and non-small cell lung cancers in adults are reviewed, with summary of evidence for use and recommendation. Current development in biomarker studies is also discussed. Computerized literature searches of PubMed (National Library of Medicine), the Cochrane Collaboration Library, and commonly accepted US and international guidelines (American Society of Clinical Oncology, European Society for Medical Oncology, and National Comprehensive Cancer Network) were performed from 2001 to 2012. Literature published before 2001 was noted for historical interest but not evaluated. Literature review was focused on available systematic reviews and meta-analyses of published predictive (associated with treatment response and/or efficacy) and prognostic (associated with disease outcome) biomarkers of known therapeutic targets in colorectal, breast, and non-small cell lung cancers. In general, significant health outcomes (e.g. predicted response to therapy, overall survival, disease-free survival, quality of life, lesser toxicity, and cost-effectiveness) were used for making recommendations. Four breast cancer biomarkers were evaluated, two of which (2D6 genotyping, Oncotype Dx) were considered emerging with insufficient evidence. Seven colorectal cancer biomarkers were evaluated, five of which (EGFR gene expression, K-ras G13D gene mutation, B-raf V600E gene mutation, dihydropyrimidine dehydrogenase deficiency, and UGT1A1 genotyping) were considered emerging. Seven non-small cell lung cancer biomarkers were evaluated, five of which were emerging (EGFR gene expression, ERCC gene expression, RRM1 gene expression, K-ras gene mutation, and TS gene expression). Of all 18 biomarkers evaluated, the following showed evidence of clinical utility and were recommended for routine use in practice: ER/PR and HER2 for breast cancer; K-ras gene mutation (except G13D gene mutation) for colorectal cancer; mismatch repair deficiency or microsatellite instability for colorectal cancer; and EGFR and EML4-ALK gene mutations for non-small cell lung. Not all recommendations for these biomarkers were uniformly supported by all guidelines.

Alcohol-induced blackout as a criminal defense or mitigating factor: an evidence-based review and admissibility as scientific evidence

Alcohol-related amnesia--alcohol blackout--is a common claim of criminal defendants. The generally held belief is that during an alcohol blackout, other cognitive functioning is severely impaired or absent. The presentation of alcohol blackout as scientific evidence in court requires that the science meets legal reliability standards (Frye, FRE702/Daubert). To determine whether "alcohol blackout" meets these standards, an evidence-based analysis of published scientific studies was conducted. A total of 26 empirical studies were identified including nine in which an alcohol blackout was induced and directly observed. No objective or scientific method to verify the presence of an alcoholic blackout while it is occurring or to confirm its presence retrospectively was identified. Only short-term memory is impaired and other cognitive functions--planning, attention, and social skills--are not impaired. Alcoholic blackouts would not appear to meet standards for scientific evidence and should not be admissible.

Prognosis following neonatal brachial plexus palsy: an evidence-based review

PURPOSE

The spontaneous recovery rate of neonatal brachial plexus palsy (NBPP) is often cited as 75-95%. However, recent reports have found the recovery rate to be much lower. The purpose of this study was to perform an evidence-based review aimed at summarizing the available English language information regarding prognosis following NBPP based on the Narakas classification.

METHODS

A Medline database search was performed to identify articles that focused on the natural history, outcome, prognosis, or conservative treatment of neonatal brachial plexus birth injury from 1966 to 2006. Twenty-four articles were identified. The articles were graded according to the Oxford Evidence Based Grading Scale and data regarding sample size, follow up, study purpose, Narakas grouping, Mallet scale, and recovery of function at 3 and 6 months were extracted. Of the 24 articles, 11 were included for review. Data analysis included odds ratios and percent recovery.

RESULTS

Of the 11 studies, only one was given a grade of a Level I study, three were given a grade of Level II, and seven were given a grade of Level IV. Sixty-four percent of infants classified as Narakas I and II had spontaneous recovery of biceps function at 3 months of age and only 9% of the Narakas III and IV group had recovery. Sixty-five percent of the Narakas I and II group had complete recovery at 6 months of age and only 14% of the Narakas III and IV group had recovery. The odds of biceps recovery at 3 months of age for the Narakas I and II group was 19 times higher compared to the III and IV group. The odds of complete recovery were 11 times higher for the Narakas I and II group compared to the III and IV group.

CONCLUSION

The quality of the literature regarding the prognosis of neonatal brachial plexus injury is poor. Based on the Narakas classification, recovery better for NBPP classified as Narakas I and II.

Perindopril: the evidence of its therapeutic impact in hypertension

INTRODUCTION

Effective antihypertensive therapy reduces the risk of cardiovascular and cerebrovascular disease and death. Perindopril, a long-acting angiotensin-converting enzyme (ACE) inhibitor, is an established antihypertensive agent administered as a once-daily tablet.

AIMS

To review recent evidence for the use of perindopril in the treatment of hypertension.

EVIDENCE REVIEW

Evidence shows that perindopril alone or in combination with other antihypertensive agents can achieve clinically significant reductions in blood pressure after 12 weeks of treatment. There is strong evidence from large randomized studies that perindopril-based therapy reduces the risk of cardiovascular outcomes, including mortality, in patients with coronary artery disease and those who have had a prior stroke or transient ischemic attack. There is also some evidence that these effects are greater than those achieved by blood pressure reduction alone, suggesting other drug-related effects including improvements in endothelial function. Recent results have also shown that an amlodipine ± perindopril regimen prevented more major cardiovascular events than an atenolol-based regimen in patients with hypertension, as a result of better control of blood pressure. Economic evidence from one major study shows that, for most patients, the incremental cost per quality-adjusted life-year gained with perindopril 8 mg was lower than the threshold value of €20 000 (73-92% of patients) in Europe or £20 000 (94% of patients) in the UK.

CLINICAL VALUE

There is strong evidence supporting the use of perindopril-based therapy for the treatment of hypertension and reduction in the risk of cardiovascular disease, stroke, and death in a wide range of patients with stable coronary artery disease or hypertension.

Insulin glargine in the management of diabetes mellitus: an evidence-based assessment of its clinical efficacy and economic value

INTRODUCTION

Diabetes is a chronic disease associated with high morbidity and mortality, which represents a major public health concern. Interventions that can enhance patient care and reduce clinic visits will not only relieve some of this burden, they will also improve patient QOL and wellbeing.

AIMS

This review assesses the evidence for the use of insulin glargine in type 1 and type 2 diabetes mellitus.

EVIDENCE REVIEW

Once-daily insulin glargine has a prolonged, peakless activity profile, making it a candidate as a long-acting (basal) insulin. In combination with bolus insulin to cover prandial glucose surges, it facilitates a more physiologic approach to patient management. Evidence from large, randomized, controlled clinical trials in patients with type 1 diabetes has confirmed its effectiveness and tolerability relative to neutral protamine hagedorn (NPH) insulin, with a tendency toward causing less hypoglycemia. In patients with type 2 diabetes requiring insulin therapy, once-daily insulin glargine has proven to be clinically superior to NPH insulin in terms of providing at least as effective glycemic control, but with significantly fewer episodes of nocturnal hypoglycemia. A variety of economic analyses have confirmed the cost effectiveness of insulin glargine in type 1 and type 2 diabetes and in particular it was shown to be significantly superior to NPH insulin.

CLINICAL VALUE

Insulin glargine has established itself as a first-line choice in patients with type 1 diabetes, including children (>6 years) and adolescents, and is a recommended treatment option. In patients with type 2 diabetes it is clearly associated with less hypoglycemia than NPH insulin, and this may help overcome one of the major barriers to starting insulin therapy in this class of patient. Thus, insulin glargine is a valuable addition to the therapeutic armamentarium available to physicians and it has the potential to significantly improve the quality of life of patients with diabetes.

FTY720 in multiple sclerosis: the emerging evidence of its therapeutic value

INTRODUCTION

Multiple sclerosis is a demyelinating disease of the central nervous system which can cause severe disability and has profound effects on patients' quality of life over several decades. Although there is no cure for the disease, recently developed disease-modifying agents have modest effects on the impact of disease progression. There is therefore a need for a new, effective, and well-tolerated treatment for multiple sclerosis and FTY720 (an orally administered immunomodulatory compound with a novel mechanism of action) is one of a number of agents being evaluated for the treatment of this disease.

AIMS

The objective of this article is to assess the therapeutic potential for FTY720, now in phase II clinical trials, for the treatment of multiple sclerosis through a review of the published evidence.

EMERGING EVIDENCE

There is good evidence that FTY720 achieves immunomodulation as shown by a reversible redistribution of peripheral blood lymphocytes after oral administration. Two meeting abstracts have been published showing results obtained with FTY720 in a 12-month phase II clinical trial in patients with active relapsing multiple sclerosis. There is modest evidence that FTY720 significantly improves both patient-oriented (relapse rate) and disease-oriented outcomes (inflammatory disease activity). There is good evidence that FTY720 is well tolerated.

PROFILE

Based on these early results from the clinical development program, FTY720 has the potential to be an effective disease-modifying agent for the treatment of multiple sclerosis. Further results from ongoing multinational phase III studies are awaited.

Dutasteride: an evidence-based review of its clinical impact in the treatment of benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common condition affecting older men. Bothersome symptoms can progress to serious complications such as acute urinary retention (AUR) requiring surgical intervention. Dutasteride, a dual 5-alfa-reductase (5AR) inhibitor (5ARI), is a recently introduced therapy for the treatment of BPH.

AIMS

The objective of this article is to review the evidence for the treatment of BPH with dutasteride.

EVIDENCE REVIEW

Evidence from large clinical studies shows that men with an enlarged prostate achieve a measurable decrease in prostate volume by up to 26% after 4 years of treatment with dutasteride and urinary symptoms improve after 6 months of treatment. This is achieved by rapid suppression (through inhibition of 5AR) of the principal androgen (dihydrotestosterone or DHT) responsible for stimulating prostatic growth. Evidence suggests that dutasteride treatment results in a reduction in risk (rather than delay) of the most serious complications including episodes of AUR and the need for BPH-related surgery. Early symptom relief has been achieved with the combination of an alfa blocker and dutasteride. There is good evidence that dutasteride is well tolerated; side effects limited to sexual dysfunction (reduced libido, impotence, and gynecomastia) are more common compared with placebo but occur with a similar incidence to finasteride, another 5ARI. No pharmacoeconomic evidence from studies with dutasteride has so far been published.

CLINICAL VALUE

In conclusion, dutasteride is a valuable treatment option in men with moderate to severe BPH. Reductions in prostate volume lead to symptom relief and serious complications appear to be reduced.