Is Telemedicine Suitable for Patients with Chronic Inflammatory Skin Conditions? A Systematic Review.

Telemedicine, the provision of remote healthcare, has gained prominence, accelerated by the COVID-19 pandemic. It has the potential to replace routine in-person follow-up visits for patients with chronic inflammatory skin conditions. However, it remains unclear whether telemedicine can effectively substitute in-person consultations for this patient group. This systematic review assessed the effectiveness and safety of telemedicine compared with traditional in-person care for chronic inflammatory skin diseases. A comprehensive search in various databases identified 11 articles, including 5 randomized controlled trials (RCTs) and 1 clinical controlled trial (CCT). These studies evaluated telemedicine's impact on patients with psoriasis and atopic dermatitis, with varying methods like video consultations and digital platforms. The findings tentatively suggest that telemedicine does not seem to be inferior compared with in-person care, particularly in terms of condition severity and quality of life for patients with chronic inflammatory skin diseases. However, these results should be interpreted with caution due to the inherent uncertainties in the evidence. There are indications that telemedicine can offer benefits such as cost-effectiveness, time savings, and reduced travel distances, but it is important to recognize these findings as preliminary, necessitating further validation through more extensive research.

Assessing variability in results in systematic reviews of diagnostic studies.

BACKGROUND: To describe approaches used in systematic reviews of diagnostic test accuracy studies for assessing variability in estimates of accuracy between studies and to provide guidance in this area. METHODS: Meta-analyses of diagnostic test accuracy studies published between May and September 2012 were systematically identified. Information on how the variability in results was investigated was extracted. RESULTS: Of the 53 meta-analyses included in the review, most (n=48; 91%) presented variability in diagnostic accuracy estimates visually either through forest plots or ROC plots and the majority (n=40; 75%) presented a test or statistical measure for the variability. Twenty-eight reviews (53%) tested for variability beyond chance using Cochran's Q test and 31 (58%) reviews quantified it with I(2). 7 reviews (13%) presented between-study variance estimates (τ(2)) from random effects models and 3 of these presented a prediction interval or ellipse to facilitate interpretation. Half of all the meta-analyses specified what was considered a significant amount of variability (n=24; 49%). CONCLUSIONS: Approaches to assessing variability in estimates of accuracy varied widely between diagnostic test accuracy reviews and there is room for improvement. We provide initial guidance, complemented by an overview of the currently available approaches.

Incorporating quality assessments of primary studies in the conclusions of diagnostic accuracy reviews: a cross-sectional study.

BACKGROUND: Drawing conclusions from systematic reviews of test accuracy studies without considering the methodological quality (risk of bias) of included studies may lead to unwarranted optimism about the value of the test(s) under study. We sought to identify to what extent the results of quality assessment of included studies are incorporated in the conclusions of diagnostic accuracy reviews. METHODS: We searched MEDLINE and EMBASE for test accuracy reviews published between May and September 2012. We examined the abstracts and main texts of these reviews to see whether and how the results of quality assessment were linked to the accuracy estimates when drawing conclusions. RESULTS: We included 65 reviews of which 53 contained a meta-analysis. Sixty articles (92%) had formally assessed the methodological quality of included studies, most often using the original QUADAS tool (n = 44, 68%). Quality assessment was mentioned in 28 abstracts (43%); with a majority (n = 21) mentioning it in the methods section. In only 5 abstracts (8%) were results of quality assessment incorporated in the conclusions. Thirteen reviews (20%) presented results of quality assessment in the main text only, without further discussion. Forty-seven reviews (72%) discussed results of quality assessment; the most frequent form was as limitations in assessing quality (n = 28). Only 6 reviews (9%) further linked the results of quality assessment to their conclusions, 3 of which did not conduct a meta-analysis due to limitations in the quality of included studies. In the reviews with a meta-analysis, 19 (36%) incorporated quality in the analysis. Eight reported significant effects of quality on the pooled estimates; in none of them these effects were factored in the conclusions. CONCLUSION: While almost all recent diagnostic accuracy reviews evaluate the quality of included studies, very few consider results of quality assessment when drawing conclusions. The practice of reporting systematic reviews of test accuracy should improve if readers not only want to be informed about the limitations in the available evidence, but also on the associated implications for the performance of the evaluated tests.

Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis.

PURPOSE: To provide an overview of available clinical evaluation tests for scaphoid fractures and to compare their diagnostic accuracies. METHODS: PWe performed a systematic review of all studies assessing diagnostic characteristics of clinical evaluation in scaphoid fractures by searching MEDLINE, EMBASE, Cochrane, and CINAHL databases. Only studies on clinical testing prior to radiographic evaluation and with acceptable reference standard for occult fractures were included. Thirteen relevant articles were analyzed that described a total of 25 tests. Diagnostic characteristics of the tests were used to construct contingency tables. If possible, data were pooled and summary receiver operating characteristic curves were fitted. RESULTS: Anatomic snuff-box tenderness (ASB, 8 studies, 1,164 patients) and longitudinal thumb compression (LTC, 8 studies, 961 patients) had sufficient data for statistical analyses. Sensitivity for ASB ranged from 0.87 to 1.00; for LTC, 0.48 to 1.00. Specificity of ASB ranged from 0.03 to 0.98; for LTC, 0.22 to 0.97. Owing to considerable heterogeneity, pooled estimate points were not calculated. Other high-sensitivity tests were scaphoid tubercle tenderness, with sensitivity and specificity ranging from 0.82 to 1.00 and 0.17 to 0.57, respectively, and painful ulnar deviation, ranging from 0.67 to 1.00 and 0.17 to 0.60, respectively. Three studies showed that combining tests increased the specificity and post-test fracture probability while maintaining high sensitivity. Quality assessment showed high or unclear risk of bias and applicability concerns in reference standard and patient selection. Twelve study designs were prospective, and 1 was retrospective. CONCLUSIONS: Anatomical snuff box tenderness was the most sensitive clinical test. The low specificity of the clinical tests may result in a considerable number of overtreated patients. Combining tests improved the post-test fracture probability. This can be used to limit unnecessary immobilization, number of hospital visits, and use of imaging. The data presented herein may help to develop clinical prediction rules that could increase specificity without reducing sensitivity. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Pharmacological treatment of dementia: a scoping review of systematic reviews.

BACKGROUND: Until now, multiple reviews on the pharmacological treatment of dementia have been published. METHODS: We performed a scoping review to summarize research findings and to identify gaps in the existing literature. We searched the literature and assessed the risk of bias of the included reviews. A team of clinical experts assessed the fields in which more research is necessary. Fifty-five reviews with a low risk of bias were included, most of them concerning the treatment of cognitive decline (n = 16) and behavioral symptoms (n = 10) in Alzheimer's disease (AD). For cognitive impairment, cholinesterase inhibitors (n = 13) and memantine (n = 7) were described most frequently. Little information was found about the treatment of depression in dementia. CONCLUSIONS: For many current treatments, there is sufficient evidence. New research should focus on the symptomatic treatment of the earliest and most salient complaints in AD as well as on disease-modifying interventions acting at the level of the amyloid cascade.

[Guidelines in historical perspective]. / Richtlijnen in historisch perspectief.

The role of clinical practice guidelines has changed dramatically the past 50 years. Both beneficial, as also having some disadvantageous effects. Considering the international developments, such as a growing body of evidence and evolving methodologies, some limits might be in reach or already been reached. The solution thereof is part nationally and part internationally. Internationally because of new methodologies and technologies, such as use of artificial intelligence, and nationally in a more coherent approach. Coherent not only in medical disciplines, but also in policies of government, regulators, and health insurers. This calls for a renewed, integral and an all-encompassing vision.

A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis.

Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.

Meta-epidemiologic analysis indicates that MEDLINE searches are sufficient for diagnostic test accuracy systematic reviews.

OBJECTIVES: To investigate how the summary estimates in diagnostic test accuracy (DTA) systematic reviews are affected when searches are limited to MEDLINE. STUDY DESIGN AND SETTING: A systematic search was performed to identify DTA reviews that had conducted exhaustive searches and included a meta-analysis. Primary studies included in selected reviews were assessed to determine whether they were indexed on MEDLINE. The effect of omitting non-MEDLINE studies from meta-analyses was investigated by calculating the summary relative diagnostic odds ratio (RDORs) = DORMEDLINE only/DORall studies. We also calculated the summary difference in sensitivity and specificity between all studies and only MEDLINE-indexed studies. RESULTS: Ten reviews contributing 15 meta-analyses met inclusion criteria for quantitative analysis. The RDOR comparing MEDLINE-only studies with all studies was 1.04 (95% confidence interval [CI], 0.95, 1.15). Summary estimates of sensitivity and specificity remained almost unchanged (difference in sensitivity: -0.08%; 95% CI -1% to 1%; difference in specificity: -0.1%; 95% CI -0.8% to 1%). CONCLUSION: Restricting to studies indexed on MEDLINE did not influence the summary estimates of the meta-analyses in our sample. In certain circumstances, for instance, when resources are limited, it may be appropriate to restrict searches to MEDLINE. However, the impact on individual reviews cannot be predicted.

Systematic overview finds variation in approaches to investigating and reporting on sources of heterogeneity in systematic reviews of diagnostic studies.

OBJECTIVES: To examine how authors explore and report on sources of heterogeneity in systematic reviews of diagnostic accuracy studies. STUDY DESIGN AND SETTING: A cohort of systematic reviews of diagnostic tests was systematically identified. Data were extracted on whether an exploration of the sources of heterogeneity was undertaken, how this was done, the number and type of potential sources explored, and how results and conclusions were reported. RESULTS: Of the 65 systematic reviews, 12 did not perform a meta-analysis and eight of these gave heterogeneity between studies as a reason. Of the 53 reviews containing a meta-analysis, 40 explored potential sources of heterogeneity in a formal manner and 27 identified at least one source of heterogeneity. The reviews not investigating heterogeneity were smaller than those that did (median [interquartile range {IQR}], 8 [5-15] vs. 14 [11-19] primary studies). Twelve reviews performed a sensitivity analysis, 25 stratified analyses, and 19 metaregression. Many sources of heterogeneity were explored compared with the number of primary studies in a meta-analysis (median ratio, 1:5). Review authors placed importance on the exploration of sources of heterogeneity; 37 mentioned the exploration or the findings thereof in the abstract or conclusion of the main text.results CONCLUSION: Methods for investigating sources of heterogeneity varied widely between reviews. Based on our findings of the review, we made suggestions on what to consider and report on when exploring sources of heterogeneity in systematic reviews of diagnostic studies.

Identification of additional trials in prospective trial registers for Cochrane systematic reviews.

BACKGROUND: Publication and selective outcome reporting bias are a threat to the validity of systematic reviews. Extensive searching for additional trials in prospective trial registers could reduce this problem. We have evaluated how authors of Cochrane systematic reviews currently make use of trial registers as an additional source for the identification of potentially eligible trials. METHODOLOGY/PRINCIPAL FINDINGS: We included 210 systematic Cochrane reviews of interventions published between 2008 and 2010 of which the protocol was first published in 2008. When prospective trial registers were searched we recorded the names of the register(s), the authors' motive(s) and if they yielded any extra trials. In 80 reviews (38.1%) the authors had searched in one or more prospective trial register(s) of which 55% had searched in overlapping search portals and individual registers. Most frequently assessed were the MetaRegister (66.3%) and Clinicaltrials.gov (60%) which is in sharp contrast of other registers or portals like the WHO ICTRP Search Portal (20%). Reported motives to use registers were to identify ongoing trials (83.3%), to identify unpublished outcomes or trials (23.5%), to identify recently published trials (11.8%), or to identify any relevant trial (3.9%).In 28 reviews (35%) the authors had selected (ongoing) trials identified in trial registers as potentially eligible. DISCUSSION: Trial registers as an additional source of information are gaining acknowledgement amongst Cochrane reviewers. Nevertheless, searches seem to be inefficient as overlapping databases are frequently consulted, while the WHO ICTRP Search Portal that includes the data from all approved registers worldwide is being underused. Moreover, the emphasis is now on the identification of ongoing trials, although the prospective registers offer a broader potential. Further familiarity of registers and guidance how to search and to report will help to implement this as a common method and utilize the full potential of prospective trial registers for systematic reviews.