Recommendations for managing adults with chronic non-cancer pain in primary care: A systematic clinical guideline review.

RATIONALE: Chronic non-cancer pain (CNCP) is a leading driver of disability. Primary care clinicians treat most patients with CNCP. Yet, they are often unable to identify appropriate pain treatments, mainly due to concerns about the safety and effectiveness of available medications. Clinical practice guidelines (CPGs) can be useful tools to guide primary care clinicians in selecting pain treatments based on the best available evidence. OBJECTIVES: To undertake a systematic review of CPGs that address the management of adults with CNCP, regardless of underlying condition type, in primary care. METHOD: We systematically reviewed and synthesised current CPGs for managing adults with CNCP in primary care (2013-2023). We followed a stepwise systematic process to synthesise key CPG recommendations: extracted and analysed each recommendation, synthesised by compiling similar recommendations using a thematic analysis approach, and assessed the strength of CPG recommendations to create a final, unified set of recommendations. We focused on identifying CPGs containing recommendations on the following topics: (a) opioid pain management, (b) non-opioid pharmacological pain management, (c) non-pharmacological pain management, and (d) patient-centred communication around pain management, prevention, and organisation of care. RESULTS: We included 13 CPGs, 8 of which focused solely on use of opioids, emphasising the lack of long-term effectiveness and safety concerns, being mainly based on the expert consensus. As an exception, high-quality evidence recommended referring patients with suspected opioid use disorder to specialist addiction services for medication-assisted treatment. Recommendations for non-opioid pain management were often contradictory and based on the expert consensus. Patient-centred pain management combined with exercise-based interventions and psychological therapies are appropriate strategies for managing patients with CNCP. CONCLUSION: Most CPGs focused on opioid management, with contradictory recommendations for non-opioid management based on low-quality evidence. Additional research is needed to strengthen the evidence for using non-opioid and non-pharmacological interventions to manage patients with CNCP.

A Month of Vestibular Migraine: Symptom Characterization Using Ecological Momentary Assessment.

OBJECTIVE(S): This study investigated the frequency and intensity of vestibular migraine (VM) symptoms using Ecological Momentary Assessment (EMA). This approach was intended to provide insights into the day-to-day experiences of individuals with VM, contributing to a more comprehensive understanding of this condition. METHODS: Participants reported symptoms to an automated text system, rating their dizziness over the prior 24 h as none, mild, moderate, or severe. Definitive Dizzy Days (DDDs) were defined as days with moderate or severe dizziness. A student's independent group t-test was used to compare the number of DDDs between VM and probable VM subjects. RESULTS: Sixty-six subjects were included, with an average of 29 days of pre-intervention data (SD = 1.4). The average number of days with no dizziness was 3.5 (SD = 6.5), mild dizziness was 9.1 (SD = 6.7), moderate dizziness was 11 (SD = 6.1), and severe dizziness was 5.4 (SD = 6.3). Out of the 66 patients, 52 were classified as VM and 14 as pVM. The average number of DDDs was not significantly different between VM (17.0, SD = 8.3) and pVM (15.3, SD = 10.0) patients, with a two-tailed p-value of 0.44. CONCLUSION: With EMA, we found that the average subject with VM had some degree of dizziness almost every day, and more than 15 DDDs per month. LEVEL OF EVIDENCE: III Laryngoscope, 2024.

Applying current European periodontitis clinical practice guidelines is not feasible even for the richest countries in the world.

Clinical practice guidelines aim to enhance the quality, equality and consistency of care but often demand more time than is available, rendering adherence impractical and exceeding feasible resources. The 2017 introduction of a new periodontal classification system by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) sought to refine clinical and epidemiological practices by serving as the basis for clinical practice guidelines and epidemiological investigations around the world. Following this classification, the EFP recommends supportive periodontal care visits every 3-12 months for all periodontitis cases. Given that in Norway, approximately 72% of the adult population are identified as periodontitis cases under the current AAP/EFP case definition, this poses a significant demand on healthcare resources. We calculated that between 60% and 70% of all estimated available working hours available for adult dental care provided by dentists and dental hygienists in Norway in 2017 would be spent on supportive periodontal care visits alone if the recommendations were to be met. This situation calls for a reevaluation of disease definitions and clinical practice guidelines to ensure they are practical, financially feasible and patient-outcome relevant.

Surgeon-led improvement in compliance with use of sequential compression devices in a neurosurgery patient population.

INTRODUCTION: Sequential compression devices (SCDs) are the mainstay of mechanical prophylaxis for venous thromboembolism in perioperative neurosurgical patients and are especially crucial when chemical prophylaxis is contraindicated. OBJECTIVES: This study aimed to characterise and improve SCD compliance in neurosurgery stepdown patients. METHODS: SCD compliance in a neurosurgical stepdown unit was tracked across 13 months (August 2022-August 2023). When not properly functioning, the missing element was documented. Compliance was calculated daily in all patients with SCD orders, and then averaged monthly. Most common barriers to compliance were identified. With nursing, we implemented a best practice alert to facilitate nursing education at month 3 and tracked compliance over 9 months, with two breaks in surveillance. At month 12, we implemented a patient-engagement measure through creating and distributing a patient-directed infographic and tracked compliance over 2 months. RESULTS: Compliance averaged 19.7% (n=95) during August and 38.4% (n=131) in September. After implementing the best practice alert and supply chain upgrades, compliance improved to 48.8% (n=150) in October, 41.2% (n=104) in March and 45.9% (n=76) in April. The infographic improved compliance to 51.4% (n=70) in July and 55.1% (n=34) in August. Compliance was significantly increased from baseline in August to October (z=4.5838, p<0.00001), sustained through March (z=3.2774, p=0.00104) and further improved by August (z=3.9025, p=0.0001). CONCLUSION: Beyond an initial Hawthorne effect, implementation of the best practice nursing alert facilitated sustained improvement in SCD compliance despite breaks in surveillance. SCD compliance nonetheless remained below 50% until implementation of patient-engagement measures which were dependent on physician involvement.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

Predictors of computed tomography imaging in patients presenting with sudden hearing loss.

Objective: Sudden sensorineural hearing loss (SSNHL) is a rare presentation requiring timely diagnosis and treatment. Despite recommendations against obtaining computed tomography (CT) imaging of the head in clinical practice guidelines, this investigation is often completed in patients with sudden hearing loss. The aim of this study was to determine the proportion of patients undergoing CT imaging of the head for SSNHL at our center and identify predictive factors for the use of CT imaging. Methods: Retrospective chart review of adult patients referred for SSNHL to two academic otology/neurotology practices between January 2018 and May 2021. Patient demographics, comorbid medical conditions, associated symptoms, location of initial presentation, audiologic results, and completed imaging studies were collected. Statistical analysis was performed with SPSS software. Results: Ninety-eight patients with audiologically confirmed SSNHL were included. Twenty-two patients (22.4%) underwent CT imaging as an investigation for SSNHL. The presence of vertigo (odds ratio 6.90; 95% confidence interval 2.43, 19.56) and presentation to the emergency room (odds ratio 8.71; 95% confidence interval 3.02, 25.16) were significantly associated with undergoing CT imaging. These two variables were statistically significant independent predictors of CT imaging on multivariate regression analysis (p = .01, p = .001, respectively). Conclusion: A significant proportion of patients with SSNHL undergo low-yield CT imaging of the head, particularly patients presenting to the emergency room with vertigo. These results highlight an opportunity for focused education and quality improvement initiatives.Level of evidence: 4.

Evaluating the impact of the global evidence, local adaptation (GELA) project for enhancing evidence-informed guideline recommendations for newborn and young child health in three African countries: a mixed-methods protocol.

BACKGROUND: Poverty-related diseases (PRD) remain amongst the leading causes of death in children under-5 years in sub-Saharan Africa (SSA). Clinical practice guidelines (CPGs) based on the best available evidence are key to strengthening health systems and helping to enhance equitable health access for children under five. However, the CPG development process is complex and resource-intensive, with substantial scope for improving the process in SSA, which is the goal of the Global Evidence, Local Adaptation (GELA) project. The impact of research on PRD will be maximized through enhancing researchers and decision makers' capacity to use global research to develop locally relevant CPGs in the field of newborn and child health. The project will be implemented in three SSA countries, Malawi, South Africa and Nigeria, over a 3-year period. This research protocol is for the monitoring and evaluation work package of the project. The aim of this work package is to monitor the various GELA project activities and evaluate the influence these may have on evidence-informed decision-making and guideline adaptation capacities and processes. The specific project activities we will monitor include (1) our ongoing engagement with local stakeholders, (2) their capacity needs and development, (3) their understanding and use of evidence from reviews of qualitative research and, (4) their overall views and experiences of the project. METHODS: We will use a longitudinal, mixed-methods study design, informed by an overarching project Theory of Change. A series of interconnected qualitative and quantitative data collections methods will be used, including knowledge translation tracking sheets and case studies, capacity assessment online surveys, user testing and in-depth interviews, and non-participant observations of project activities. Participants will comprise of project staff, members of the CPG panels and steering committees in Malawi, South Africa and Nigeria, as well as other local stakeholders in these three African countries. DISCUSSION: Ongoing monitoring and evaluation will help ensure the relationship between researchers and stakeholders is supported from the project start. This can facilitate achievement of common goals and enable researchers in South Africa, Malawi and Nigeria to make adjustments to project activities to maximize stakeholder engagement and research utilization. Ethical approval has been provided by South African Medical Research Council Human Research Ethics Committee (EC015-7/2022); The College of Medicine Research and Ethics Committee, Malawi (P.07/22/3687); National Health Research Ethics Committee of Nigeria (01/01/2007).

Minimally Invasive Glaucoma Surgery (MIGS) recommendations in Clinical Practice Guidelines for open angle glaucoma and MIGS procedures: A scoping review.

Introduction: To assess the recommendations of open angle glaucoma Clinical Practice Guidelines (CPG) addressing Minimally Invasive Glaucoma Surgery (MIGS) or MIGS procedures CPG. Methods: A scoping review of CPG was conducted, based on an ongoing systematic review (CRD42024510656). A systematic literature search of CPG was carried out in November 2023, with an update in January 2024. CPG published in the last 8 years, full text available and addressing MIGS were selected. CPG details and recommendations concerning MIGS were extracted. Results: 13 CPG addressing MIGS were selected (8 recovered from databases and 5 from registers). Four health Technology Assessments were assessed but recommendations were not considered. Finnish and Swedish guidelines, published in 2024, and Japanese guidelines, published in 2023, are English versions of their native language guidelines, but none of them make specific recommendations about MIGS. The Spanish Glaucoma Society - Advanced Glaucoma guideline (2023) describes the available techniques but does not make recommendations about MIGS. The European Glaucoma Society (2023) guideline only makes recommendations for 4 devices and the National Institute for Health and Care Excellence Interventional procedures guidance makes recommendations both for specific procedures and devices. Conclusion: MIGS is a relevant topic that has not been adequately addressed in terms of updated evidence, available procedures, and recommendations in open angle glaucoma CPG or MIGS procedures CPG.

Reliability of Anthropometric Measurement of Young Children with Parent Involvement.

Background: The purpose of this study was to determine the reliability of anthropometric measurements between two trained anthropometrists working in a team and one trained anthropometrist working with a child's parent/caregiver in a primary health care setting. Study Design: An observational study to determine measurement reliability was conducted in a primary care child research network in Canada. In total, 120 children 0-5 years old had their anthropometric measurement taken twice by two trained anthropometrists working in a team and twice by one trained anthropometrist working with a child's parent/caregiver. Inter- and intra-observer reliability was calculated using the technical error of measurement (TEM), relative TEM (%TEM), and the coefficient of reliability (R). Results: The %TEM values for length/height and weight were <2%, and the R coefficient values were >0.99, indicating a high degree of inter- and intra-observer reliability. The TEM values demonstrated a high degree of reliability for inter- and intra-observer measurement of length/height in comparison with other anthropometric measurement parameters. However, there was greater variation seen in the length measurement for children 0 to <2 years of age and in arm circumference measurement across both age-groups. Conclusion(s): This study suggests that anthropometric measurement taken by one trained anthropometrist with the assistance of a parent/caregiver is reliable. These findings provide evidence to support inclusion of a child's parent/caregiver with anthropometric measurement collection in clinical setting(s) to enhance feasibility and efficiency and reduce the research costs of including a second trained anthropometrist.

Transparency Matters: Assessing Harms Reporting Compliance in Randomized Controlled Trials Underpinning the AAOS Clinical Practice Guideline for Anterior Cruciate Ligament Injuries.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) has developed a clinical practice guideline (CPG) for management of anterior cruciate ligament (ACL) injuries. Primary studies such as randomized controlled trials (RCTs) are cited as evidence for the guidelines. Given the influence that these trials have on patient care, adherence to standardized protocols for conducting and reporting RCTs is essential. PURPOSE: To evaluate the CONSORT (Consolidated Standards of Reporting Trials) Extension for Harms-related reporting of RCTs cited as supporting evidence for the AAOS CPG on the management of ACL tears. STUDY DESIGN: Cross-sectional study. METHODS: The reference section of the AAOS guideline for ACL tears was first screened for RCTs cited in the CPG. Next, each RCT was evaluated for adherence to the CONSORT Extension for Harms checklist. Both identification of RCTs and assessment of adherence were performed in a masked and duplicate process. Descriptive statistics were used to summarize adherence to CONSORT Extension for Harms items. A Pearson correlation test was conducted to assess the relationship between the year of publication and adherence to CONSORT harms reporting. RESULTS: The sample included 113 RCTs, of which 16 (14.2%) were published before the CONSORT Extension for Harms was implemented in 2004. Sample sizes ranged from 24 to 4564 participants, with a mean of 228. None of the included RCTs included all 18 items in the CONSORT Extension for Harms checklist. The mean number of checklist items reported was 4 (of 18; 22.2%). A moderate, positive, and statistically significant correlation was found between the RCT publication year and the adherence with reporting of the CONSORT Extension for Harms (t111 = 3.54; P < .001) (r = 0.32; 95% CI, 0.14-0.47). CONCLUSION: Harms were infrequently reported in RCTs cited as supporting evidence in the AAOS CPG for the management of ACL tears. One encouraging finding was the positive correlation between the year when RCTs were published and how well they adhered to reporting harms. Efforts to improve adverse event reporting are warranted, as RCTs are commonly used to make clinical decisions in orthopaedic surgery.

European Society of Cardiology quality indicators update for the care and outcomes of adults with heart failure. The Heart Failure Association of the ESC.

AIMS: To update the European Society of Cardiology (ESC) quality indicators (QIs) for the evaluation of the care and outcomes of adults with heart failure. METHODS AND RESULTS: The Working Group comprised experts in heart failure including members of the ESC Clinical Practice Guidelines Task Force for heart failure, members of the Heart Failure Association, and a patient representative. We followed the ESC methodology for QI development. The 2023 focused guideline update was reviewed to assess the suitability of the recommendations with strongest association with benefit and harm against the ESC criteria for QIs. All the new proposed QIs were individually graded by each panellist via online questionnaires for both validity and feasibility. The existing heart failure QIs also underwent voting to 'keep', 'remove' or 'modify'. Five domains of care for the management of heart failure were identified: (1) structural QIs, (2) patient assessment, (3) initial treatment, (4) therapy optimization, and (5) patient health-related quality of life. In total, 14 'main' and 3 'secondary' QIs were selected across the five domains. CONCLUSION: This document provides an update of the previously published ESC QIs for heart failure to ensure that these measures are aligned with contemporary evidence. The QIs may be used to quantify adherence to clinical practice as recommended in guidelines to improve the care and outcomes of patients with heart failure.

Pediatric femoral shaft fractures: the American Academy of Orthopaedic Surgeons clinical practice guidelines versus actual management in a teaching hospital.

Background: In 2009, the clinical practice guidelines (CPG) were released by the American Academy of Orthopaedic Surgeons (AAOS), which outline an age-based approach for treating pediatric femoral shaft fractures (PFSF), both nonoperatively and operatively. The aim of the current study was to investigate potential disparities between the recommended treatments for PFSF based on the AAOS-CPG and the actual treatments administered in The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. Methods: A retrospective review was conducted on the medical charts and radiographs of all PFSF treated at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2014 to January 2022. We identified 445 children who met our inclusion criteria and evaluated their treatments according to the AAOS-CPG. Actual treatments were then compared with the treatments recommended by the AAOS-CPG. Binomial and multivariate logistic regression was used to examine whether different factors could predict the choice between operative and nonoperative management. Results: Operative treatments were undertaken in 102 of 215 (47.4%) fractures in children younger than 6 years, in 102 of 122 (83.6%) fractures in those between 6 and 12 years of age, and in 107 of 108 (99.1%) fractures in those older than 12 years. Nonoperative management was conducted in 113 of 215 (52.6%) fractures in children younger than 6 years, in 20 of 122 (16.4%) fractures in those between 6 and 12 years of age, and in 1 of 108 (0.9%) fractures in those older than 12 years of age. Surgeon decisions for non-surgery were in agreement with the CPG 52.6% of the time, whereas agreement reached 90.9% for surgical choices. Predictors of actual operative management were age (P=0.01), patient weight (P<0.001), fracture pattern (P<0.001), presence of other orthopedic injuries requiring surgery (P=0.002), and polytrauma (P=0.02). Conclusions: There was limited concordance between actual treatments and CPG recommendations, particularly for the nonoperative management of fractures in children under 6 years old. Age, patient weight, fracture pattern, presence of other orthopedic injuries requiring surgery, and polytrauma were the main predictors of our operative decision-making process.

Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research.

OBJECTIVE: The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations. METHOD: Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations. RESULTS: The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery. CONCLUSION: These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

Challenges, barriers and solutions for implementing clinical practice guidelines: a qualitative study in southern Iran.

BACKGROUND: Identifying the challenges of implementing clinical practice guidelines (CPGs) can provide valuable information for decision-makers and health policymakers at the national and local levels. The implementation of CPGs requires the development of strategies to facilitate their use. This research aimed to determine the challenges, barriers and solutions for implementing CPGs from the expert point of view in Bushehr University of Medical Sciences. METHODS: This qualitative research uses content analysis conducted in 2022 in southern Iran. In-depth interviews were conducted with the physicians and experts in the health system. Interviewing continued until reaching the saturation level. Altogether, 22 experts were interviewed. The interview guide was used to explore experts' opinions. All the interviews were recorded and then transcribed. Finally, coding and data analysis was done using MAXQDA 2022 software. RESULTS: The analysis revealed 4 main themes and 20 subthemes. The four main themes included challenges related to physicians, medical education, the health system and patients. The most common themes were the lack of sufficient training (related to the medical education system), equipment and infrastructure, and the lack of adaptation of clinical guidelines (related to the health system). The solutions included 4 main themes and 19 subthemes. CONCLUSION: The most mentioned topic by the experts was training CPGs in medical schools. In Iran's current medical education system, the training of CPGs is not included in the curriculum. It is proposed to reform the medical education system in Iran. In addition, health inequalities such as lack of access to equipment, supplies and insurance in under-resourced areas and disparities in research/training/medical education should be addressed to improve the validity of guidelines.

Advances and Challenges in Spinal Cord Injury Treatments.

Spinal cord injury (SCI) is a debilitating condition that is associated with long-term physical and functional disability. Our understanding of the pathogenesis of SCI has evolved significantly over the past three decades. In parallel, significant advances have been made in optimizing the management of patients with SCI. Early surgical decompression, adequate bony decompression and expansile duraplasty are surgical strategies that may improve neurological and functional outcomes in patients with SCI. Furthermore, advances in the non-surgical management of SCI have been made, including optimization of hemodynamic management in the critical care setting. Several promising therapies have also been investigated in pre-clinical studies, with some being translated into clinical trials. Given the recent interest in advancing precision medicine, several investigations have been performed to delineate the role of imaging, cerebral spinal fluid (CSF) and serum biomarkers in predicting outcomes and curating individualized treatment plans for SCI patients. Finally, technological advancements in biomechanics and bioengineering have also found a role in SCI management in the form of neuromodulation and brain-computer interfaces.

Paramedic clinical practice guideline development in Australia and New Zealand: A qualitative descriptive analysis.

BACKGROUND: This collaborative study by The Australasian College of Paramedicine's Clinical Practice Guidelines (CPG) Working Group aimed to examine CPG development practices in Australian and New Zealand ambulance services. METHODS: Employing a qualitative descriptive design, the research utilised thematic analysis to extract insights from interviews with eleven experts actively involved in CPG development. The study embraced a nominalist and constructivist approach, recognising the intricate connection between individual experiences and the realities of CPG development in the paramedic field. RESULTS: Key findings revealed significant heterogeneity in CPG development practices, emphasising a lack of formal training and a substantial reliance on existing guidelines. The study highlighted challenges in project management flexibility, limited research capacity, and inconsistencies in external consultations and resource utilisation. CONCLUSION: The study recommends adopting project management frameworks, investing in training, and utilising evidence evaluation methodologies like GRADE. It emphasises the need for multidisciplinary teams and formal expertise in evidence synthesis, advocating for targeted training programs. Funding challenges highlight the importance of dedicated budgets and collaborative efforts for resource allocation. Knowledge translation and implementation issues underscore the significance of training programs for evidence evaluation and knowledge translation in overcoming these challenges.

Hospital falls clinical practice guidelines: a global analysis and systematic review.

BACKGROUND: Hospital falls continue to be a persistent global issue with serious harmful consequences for patients and health services. Many clinical practice guidelines now exist for hospital falls, and there is a need to appraise recommendations. METHOD: A systematic review and critical appraisal of the global literature was conducted, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Web of Science, Embase, CINAHL, MEDLINE, Epistemonikos, Infobase of Clinical Practice Guidelines, Cochrane CENTRAL and PEDro databases were searched from 1 January 1993 to 1 February 2024. The quality of guidelines was assessed by two independent reviewers using Appraisal of Guidelines for Research and Evaluation Global Rating Scale and Appraisal of Guidelines of Research and Evaluation Recommendation Excellence (AGREE-REX). Certainty of findings was rated using Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research. Data were analysed using thematic synthesis. RESULTS: 2404 records were screened, 77 assessed for eligibility, and 20 hospital falls guidelines were included. Ten had high AGREE-REX quality scores. Key analytic themes were as follows: (i) there was mixed support for falls risk screening at hospital admission, but scored screening tools were no longer recommended; (ii) comprehensive falls assessment was recommended for older or frail patients; (iii) single and multifactorial falls interventions were consistently recommended; (iv) a large gap existed in patient engagement in guideline development and implementation; (v) barriers to implementation included ambiguities in how staff and patient falls education should be conducted, how delirium and dementia are managed to prevent falls, and documentation of hospital falls. CONCLUSION: Evidence-based hospital falls guidelines are now available, yet systematic implementation across the hospital sector is more limited. There is a need to ensure an integrated and consistent approach to evidence-based falls prevention for a diverse range of hospital patients.

ChatGPT Responses to Frequently Asked Questions on Ménière's Disease: A Comparison to Clinical Practice Guideline Answers.

Objective: Evaluate the quality of responses from Chat Generative Pre-Trained Transformer (ChatGPT) models compared to the answers for "Frequently Asked Questions" (FAQs) from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines (CPG) for Ménière's disease (MD). Study Design: Comparative analysis. Setting: The AAO-HNS CPG for MD includes FAQs that clinicians can give to patients for MD-related questions. The ability of ChatGPT to properly educate patients regarding MD is unknown. Methods: ChatGPT-3.5 and 4.0 were each prompted with 16 questions from the MD FAQs. Each response was rated in terms of (1) comprehensiveness, (2) extensiveness, (3) presence of misleading information, and (4) quality of resources. Readability was assessed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease Score (FRES). Results: ChatGPT-3.5 was comprehensive in 5 responses whereas ChatGPT-4.0 was comprehensive in 9 (31.3% vs 56.3%, P = .2852). ChatGPT-3.5 and 4.0 were extensive in all responses (P = 1.0000). ChatGPT-3.5 was misleading in 5 responses whereas ChatGPT-4.0 was misleading in 3 (31.3% vs 18.75%, P = .6851). ChatGPT-3.5 had quality resources in 10 responses whereas ChatGPT-4.0 had quality resources in 16 (62.5% vs 100%, P = .0177). AAO-HNS CPG FRES (62.4 ± 16.6) demonstrated an appropriate readability score of at least 60, while both ChatGPT-3.5 (39.1 ± 7.3) and 4.0 (42.8 ± 8.5) failed to meet this standard. All platforms had FKGL means that exceeded the recommended level of 6 or lower. Conclusion: While ChatGPT-4.0 had significantly better resource reporting, both models have room for improvement in being more comprehensive, more readable, and less misleading for patients.

Estimated impact of guidelines-based initiation of dual antihypertensive therapy on long-term cardiovascular outcomes in 1.1 million individuals.

AIMS: Guidelines recommend initiation of dual combination antihypertensive therapy, preferably single-pill combination (SPC), in most patients with hypertension. Evidence on narrowing gaps in clinical practice relative to guidelines is limited. METHODS AND RESULTS: Monte Carlo simulation was applied to 1.1 million patients qualifying for dual combination therapy from a previously conducted retrospective analysis of clinical practice, hospital statistics, and national statistics in the UK. We provide 10-year Kaplan-Meier event rates for the primary endpoint representing a composite of nonfatal myocardial infarction, nonfatal stroke (ischemic or hemorrhagic), nonfatal heart failure hospitalization or cardiovascular death. Cox model results from a previously conducted study were utilized to estimate baseline risk, together with evidence on risk reduction from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) meta-analysis and published evidence on BP-lowering efficacy of antihypertensive therapies. In the overall population, estimated 10-year event rates for the primary endpoint in patients with 100% persistence in monotherapy were 17.0% for irbesartan (I) and 17.6% for ramipril (R). These rates were only modestly better than that observed in clinical practice (17.8%). In patients with 100% persistence in dual therapy, estimated event rates were 13.6% for combinations of Irbesartan + Amlodipine (ARR = 8.7% compared to untreated) and 14.3% for Ramipril + Amlodipine (ARR = 8.0% compared to untreated). The absolute risk of the primary endpoint was reduced by 15.9% in patients with ASCVD and 6.6% in those without ASCVD. Similarly, the absolute risk was reduced by 11.7% in diabetics and 7.8% in those without diabetes. CONCLUSION: This study represents the first to investigate guidelines-based treatment in hypertensive patients and demonstrates the opportunity for considerable risk reduction by ensuring recommended dual therapy in clinical practice, particularly in the form of SPC with high persistence, relative to no treatment or monotherapy.