Prevention after stroke: A quality assurance study.

OBJECTIVES: In 1997, the Copenhagen Stroke Study revealed that stroke was recurrent in 23% of patients admitted with a stroke. Predictors of recurrence were history of transient ischaemic attack, atrial fibrillation, male gender and hypertension. In 2011, the Danish recurrence rate was 25%. With the aim of preventing recurrent stroke, a preventive clinic was established in 2014 at the Department of Neurology, Herlev Hospital. Data from the preventive clinic are analysed in the present study. MATERIALS AND METHODS: Data from visits to the clinic from October 2014 to October 2016 were collected from electronic medical records. Data on subsequent admissions with stroke were collected from October 2014 to the end of 2017. Data were collected and analyzed as a means of quality assurance. RESULTS: Data from 1083 patients showed that half of the patients were hypertensive at discharge regardless of admission with first ever or recurrent stroke. Nurses at the clinic initiated or intensified antihypertensive medication in 40% of patients. Blood pressure was at target in 64% of patients at last visit to the clinic. Stepwise Cox proportional hazard regression analysis of 1024 patients admitted with ischaemic stroke or transient ischaemic attack showed that tobacco smoking (HR 1.80), admission with a recurrent stroke (HR 1.76) and cholesterol-lowering treatment (HR 1.67) were independent predictors of stroke recurrence. CONCLUSIONS: The recurrence rate in Denmark has remained unchanged for two decades. Risk factors for recurrence seem to change over time. Identification and treatment of actual risk factors may be a way to reduce recurrence.

Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry.

➤: Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery. ➤: The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture. ➤: The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge. ➤: The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis. ➤: The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed.

Consensus statement of the Spanish Society of Internal Medicine and the Spanish Society of Medical Oncology on secondary thromboprophylaxis in patients with cancer.

Up to 20% of cancer patients will develop some manifestation of venous thromboembolic disease (VTD) during their clinical course. VTD greatly impacts morbidity, mortality, quality of life and pharmaceutical expenditure. In addition, both thrombotic relapse and major haemorrhages derived from VTD treatment are more likely in oncological patients. To make the decision to establish secondary thromboprophylaxis as an indefinite treatment in these patients, it is important to review all the risk factors involved, whether related to the disease, the patient or the prior thrombotic event. The objectives of this consensus of the Spanish Society of Internal Medicine (Sociedad Española de Medicina Interna-SEMI) and the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica-SEOM) are to establish recommendations that help assess the risk of recurrence of VTD and haemorrhagic risk in patients with cancer, as well as to analyse the evidence that exists on the currently available drugs, which will allow the establishment of a protocol for shared decision-making with the informed patient.

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.

BACKGROUND: Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS: The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS: Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS: These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.

["European Commission Initiative on Breast Cancer": Selected Breast Cancer Screening Recommendations from the European Guidelines.] / "European Commission Initiative on Breast Cancer": Recomendaciones seleccionadas de cribado de cáncer de mama de las guías europeas.

OBJECTIVE: The European Commission Initiative on Breast Cancer (ECIBC) has developed new recommendations on breast cancer screening and diagnosis. The objective of this work was to adapt these recommendations to Spanish in order to implement and guarantee the quality and success of breast cancer screening programmes (PCCM) throughout the Spanish territory. METHODS: The new European Guidelines on Screening and Diagnosis of Breast Cancer have been prepared by a multidisciplinary panel of experts and patients (Guidelines Development Group, GDG). The recommendations inclu-ded are supported by systematic reviews of the evidence conducted by a team of researchers from the Ibero-American Cochrane Center. For its preparation, the European Commission's conflict of interest management rules were applied and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used. The GRADE evidence-to-decision (EtD) frameworks were used to minimize potential influence of interests on the recommendations. RESULTS: As a result of the systematic reviews carried out, the GDG published on the ECIBC website a list of recommendations as part of the guidelines for the screening and diagnosis of breast cancer, which were translated into Spanish in this work. CONCLUSIONS: The adaptation to Spanish of the new recommendations helps their implementation and the creation of a uniform PCCM throughout the Spanish territory. All of this improves informed decision making and the success of PCCM.

OBJETIVO: La European Commission Initiative on Breast Cancer (ECIBC) ha desarrollado nuevas recomendaciones sobre cribado y diagnóstico de cáncer de mama. El objetivo de este trabajo fue adaptar dichas recomendaciones al castellano con el fin de implementar y garantizar la calidad y el éxito de los programas de cribado de cáncer de mama (PCCM) en todo el territorio español. METODOS: Las nuevas Guías Europeas sobre Cribado y Diagnóstico de Cáncer de Mama han sido elaboradas por un panel multidisciplinar de expertos y pacientes (Guidelines Development Group, GDG). Las recomendaciones que se incluyen se apoyan en revisiones sistemáticas de la evidencia realizadas por un equipo de investigadores del Centro Cochrane Iberoamericano. Para su elaboración se aplicaron las reglas de manejo de conflicto de intereses de la Comisión Europea y se utilizó la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation). Se utilizaron los marcos de la evidencia a la decisión (EtD) de GRADE para minimizar posibles influencias de intereses en las recomendaciones. RESULTADOS: Como resultado de las revisiones sistemáticas realizadas, el GDG publicó en la web de la ECIBC una lista de recomendaciones como parte de las guías para el cribado y diagnóstico del cáncer de mama, que fueron traducidas al castellano en este trabajo. CONCLUSIONES: La adaptación al castellano de las nuevas recomendaciones ayuda a su implementación y a crear un PCCM uniforme en todo el territorio español. Todo ello mejora la toma de decisiones informadas y el éxito de los PCCM.

Sunscreen application technique amongst patients with a history of skin cancer.

BACKGROUND: Data on how patients with a history of skin cancer apply sunscreen are lacking. OBJECTIVE: To characterize (1) gender differences in sunscreen application technique (quantity used, anatomic site coverage, and time allocated) and (2) differences in sunscreen application to unaffected skin versus previous skin cancer sites. METHODS: Subjects with a history of skin cancer were asked to apply sunscreen to their head as they normally would. The amount of sunscreen used and application time were recorded. Before and after photos were taken. Using Wood's lamp lighting, an anatomic site coverage score was rated on an ordinal scale (1 = 0-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% coverage). RESULTS: Males used 530 mg more sunscreen (p < 0.001) and applied approximately 5 mg/cm2 of sunscreen versus women, who applied 2 mg/cm2. The average coverage score was 3.27. Males were 7.61 times more likely to adequately apply sunscreen to the ears (p = 0.001). No differences were noted in application times. Coverage scores were similar for unaffected skin and previous skin cancer sites. LIMITATIONS: Observations in a controlled setting may not reflect usual sunscreen application practices. CONCLUSIONS: Overall, skin cancer survivors of both genders effectively applied sunscreen in line with recommended quantity guidelines, but men were significantly better at protecting their ears.

Multicentric Italian survey on daily practice for autoimmune pancreatitis: Clinical data, diagnosis, treatment, and evolution toward pancreatic insufficiency.

BACKGROUND: Autoimmune pancreatitis (AIP) is a rare, and relatively new, form of chronic pancreatitis. The management of AIP can vary considerably among different centres in daily clinical practice. OBJECTIVES: The aim of this study is to present a picture of epidemiological, clinical characteristics, outcomes, and the real-life practice in terms of management in several academic and non-academic centres in Italy. METHODS: Data on the clinical presentation, diagnostic work-up, treatments, frequency of relapses, and long-term outcomes were retrospectively collected in a cohort of AIP patients diagnosed at 14 centres in Italy. RESULTS: One hundred and six patients were classified as type 1 AIP, 48 as type 2 AIP, and 19 as not otherwise specified. Epidemiological, clinical, radiological, and serological characteristics, and relapses were similar to those previously reported for different types of AIP. Endoscopic cytohistology was available in 46.2% of cases, and diagnostic for AIP in only 35.2%. Steroid trial to aid diagnosis was administered in 43.3% cases, and effective in 93.3%. Steroid therapy was used in 70.5% of cases, and effective in 92.6% of patients. Maintenance therapy with low dose of steroid (MST) was prescribed in 25.4% of cases at a mean dose of 5 (±1.4) mg/die, and median time of MST was 60 days. Immunosuppressive drugs were rarely used (10.9%), and rituximab in 1.7%. Faecal elastase-1 was evaluated in only 31.2% of patients, and was pathological in 59.2%. CONCLUSIONS: In this cohort of AIP patients, diagnosis and classification for subtype was frequently possible, confirming the different characteristics of AIP1 and AIP2 previously reported. Nevertheless, we observed a low use of histology and steroid trial for a diagnosis of AIP. Steroid treatment was the most used therapy in our cohort. Immunosuppressants and rituximab were rarely used. The evaluation of exocrine pancreatic insufficiency is underemployed considering its high prevalence.

Peripheral artery disease in the lower limbs: The importance of secondary risk prevention for improved long-term prognosis.

BACKGROUND: Patients with lower limb peripheral artery disease (PAD) are at high risk of cardiovascular mortality and morbidity along with limb loss. PAD is underdiagnosed in the community and presents a missed opportunity to prescribe evidence-based secondary prevention therapy. OBJECTIVE: The aim of this article is to summarise key updates in the management of patients with PAD, with particular reference to newly published guidelines. DISCUSSION: PAD continues to be a major contributor to the mortality and morbidity of patients with atherosclerosis in Australia. For patients with chronic limb-threatening ischaemia, revascularisation remains the mainstay of limb salvage, and expedited access to vascular surgery assessment is necessary. Both prescription of, and adherence to, evidence-based secondary prevention therapy is low. A greater emphasis on cardiovascular risk factor modification for all patients with PAD is required to improve long-term outcomes. General practitioners and vascular surgeons can work collaboratively to provide patient-centred, effective care to patients with PAD.

Evidence-based quality indicators for primary healthcare in association with the risk of hospitalisation: a population-based cohort study in Switzerland.

OBJECTIVES: The quality of ambulatory care in Switzerland is widely unknown. Therefore, this study aimed to evaluate the recently proposed quality indicators (QIs) based on a nationwide healthcare claims database and determine their association with the risk of subsequent hospitalisation at patient-level. DESIGN: Retrospective cohort study. SETTING: Inpatient and outpatient claims data of a large health insurance in Switzerland covering all regions and population strata. PARTICIPANTS: 520 693 patients continuously insured during 2015 and 2016. MEASURES: A total of 24 QIs were obtained by adapting the existing instruments to the Swiss national context and measuring at patient-level. The association between each QI and hospitalisation in the subsequent year was assessed using multiple logistic regression models. RESULTS: The proportion of patients with good adherence to QIs was high for the secondary prevention of diabetes and myocardial infarction (glycated haemoglobin (HbA1c) control, 89%; aspirin use, 94%) but relatively low for polypharmacy (53%) or using potentially inappropriate medications (PIMs) in the elderly (PIM, 33%). Diabetes-related indicators such as the HbA1c control were significantly associated with a lower risk of hospitalisation (OR, 0.87; 95% CI, 0.80 to 0.95), whereas the occurrence of polypharmacy and PIM increased the risk of hospitalisation in the following year (OR, 1.57/1.08; 95% CI, 1.51 to 1.64/1.05 to 1.12). CONCLUSIONS: This is the first study to evaluate the recently presented QIs in Switzerland using nationwide real-life data. Our study suggests that the quality of healthcare, as measured by these QIs, varied. The majority of QIs, in particular QIs reflecting chronic care and medication use, are considered beneficial markers of healthcare quality as they were associated with reduced risk of hospitalisation in the subsequent year. Results from this large practical test on real-life data show the feasibility of these QIs and are beneficial in selecting the appropriate QIs for healthcare implementation in general practice.

The diagnostic work-up and outcomes of 'presumed' idiopathic acute pancreatitis: A post-hoc analysis of a multicentre observational cohort.

INTRODUCTION: After standard diagnostic work-up, the aetiology of acute pancreatitis remains unknown in 16-27% of cases, a condition referred to as idiopathic acute pancreatitis (IAP). Determining the aetiology of pancreatitis is essential, as it may direct treatment in the acute phase and guides interventions to prevent recurrent pancreatitis. METHODS: Between 2008 and 2015, patients with acute pancreatitis were registered prospectively in 19 Dutch hospitals. Patients who had a negative initial diagnostic work-up with regard to the underlying aetiology of their pancreatitis were labelled 'presumed' IAP. The aim of this study was to assess the use of diagnostic modalities and their yield to establish an aetiology in 'presumed' IAP, and to assess recurrence rates both with and without treatment. RESULTS: Out of the 1632 registered patients, 191 patients had a first episode of 'presumed' IAP, of whom 176 (92%) underwent additional diagnostic testing: CT (n = 124, diagnostic yield 8%), EUS (n = 62, yield 35%), MRI/MRCP (n = 56, yield 33%), repeat ultrasound (n = 97, yield 21%), IgG4 (n = 54, yield 9%) and ERCP (n = 15, yield 47%). In 64 of 176 patients (36%) an aetiological diagnosis was established, mostly biliary (n = 39). In 13 out of 176 of patients (7%) a neoplasm was diagnosed. If additional diagnostic workup revealed an aetiology, the recurrence rate was lower in the treated patients than in the patients without a definite aetiology (15% versus 43%, p = 0.014). CONCLUSION: Additional diagnostic testing revealed an aetiology in one-third of 'presumed' IAP patients. The aetiology found was mostly biliary, but occasionally neoplasms were found. Identification of an aetiology with subsequent treatment reduced the rate of recurrence.

Alcohol-related trauma reinjury prevention with hospital-based screening in adult populations: An Eastern Association for the Surgery of Trauma evidence-based systematic review.

BACKGROUND: Unaddressed alcohol use among injured patients may result in recurrent injury or death. Many trauma centers incorporate alcohol screening, brief intervention, and referral to treatment for injured patients with alcohol use disorders, but systematic reviews evaluating the impact of these interventions are lacking. METHODS: An evidence-based systematic review was performed to answer the following population, intervention, comparator, outcomes question: Among adult patients presenting for acute injury, should emergency department, trauma center, or hospital-based alcohol screening with brief intervention and/or referral to treatment be instituted compared with usual care to prevent or decrease reinjury, hospital readmission, alcohol-related offenses, and/or alcohol consumption? A librarian-initiated query of PubMed, MEDLINE, and the Cochrane Library was performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and create recommendations. The study was registered with PROSPERO (registration number CRD42019122333). RESULTS: Eleven studies met criteria for inclusion, with a total of 1,897 patients who underwent hospital-based alcohol screening, brief intervention, and/or referral to treatment for appropriate patients. There was a relative paucity of data, and studies varied considerably in terms of design, interventions, and outcomes of interest. Overall evidence was assessed as low quality, but a large effect size of intervention was present. CONCLUSION: In adult trauma patients, we conditionally recommend emergency department, trauma center, or hospital-based alcohol screening with brief intervention and referral to treatment for appropriate patients in order to reduce alcohol-related reinjury. LEVEL OF EVIDENCE: Systematic review, Level III.

Latin American consensus on uncomplicated recurrent urinary tract infection-2018.

An estimated 20-30% of adult women who experience an initial urinary tract infection (UTI) will have recurrent infection. In these patients, prophylaxis may be considered to improve their quality of life and control overuse of antibiotics. Despite this need, there is currently no Latin American consensus on the treatment and prophylaxis of recurrent UTIs. This consensus, signed by a panel of regional and international experts on UTI management, aims to address this need and is the first step toward a Latin American consensus on a number of urogynecological conditions. The panel agrees that antibiotics should be considered the primary treatment option for symptomatic UTI, taking into account local pathogen resistance patterns. Regarding prophylaxis, immunoactive therapy with the bacterial lysate OM-89 received a grade A recommendation and local estrogen in postmenopausal women grade B recommendation. Lower-grade recommendations include behavior modification and D-mannose; probiotics (Lactobacilli), cranberries, and hyaluronic acid (and derivatives) received limited recommendations; their use should be discussed with the patient. Though considered effective and receiving grade A recommendation, antimicrobial prophylaxis should be considered only following prophylaxis with effective non-antimicrobial measures that were not successful and chosen based on the frequency of sexual intercourse and local pathogen resistance patterns.

Secondary prevention and cardiovascular care across Europe: A survey of European Society of Cardiology members' views.

INTRODUCTION: Secondary prevention of cardiovascular disease is a significant clinical challenge and despite European Society of Cardiology (ESC) Guidelines, evidence confirms sub-optimal patient care. AIM: The aim of this study was to evaluate ESC members' opinions on the current provision of cardiovascular prevention and rehabilitation services across Europe and explore barriers to guideline implementation. METHOD: Electronic surveys using a secure web link were sent to members of the ESC in eight purposively selected ESC affiliated countries. RESULTS: A total of 479 professionals completed the survey, of whom 67% were cardiologists, 8.6% general physicians, 8.2% nurses and 16.2% other healthcare professionals. Respondents were predominantly (91%) practising clinicians, generally highly motivated regarding cardiovascular disease prevention, but most reported that secondary prevention in their country was sub-optimal. The main barriers to prevention were lack of available cardiac rehabilitation programmes and long-term follow-up, patients' disease perception and professional attitudes towards prevention. While knowledge of the prevention guidelines was generally good, practices such as motivational counselling and better educational tools were called for to promote exercise, smoking cessation and for nutritional aspects. CONCLUSIONS: The provision of services focusing on the secondary prevention of cardiovascular disease varies greatly across Europe. Furthermore, despite ESC Guidelines and a strong evidence base supporting the efficacy of secondary prevention, the infrastructure and co-ordination of such care is lacking. In addition patient motivation is considered poor and some professionals remain unconvinced about the merits of prevention. The disappointing results outlined in this survey emphasise that improved tools are urgently required to educate both patients and professionals and confirm the priority of cardiovascular prevention internationally.

Effectiveness of telehealth interventions as a part of secondary prevention in coronary artery disease: a systematic review and meta-analysis.

BACKGROUND: Coronary artery disease is one of the most important health problems among heart diseases in the world, with high morbidity and mortality. Lifestyle changes in particular are recommended in the latest guidelines for implementing secondary prevention. AIM: The aim of this study was to evaluate the effectiveness of telehealth interventions as a part of secondary prevention compared to routine care in those with coronary artery disease. METHOD: The systematic review with meta-analysis was performed in accordance with Cochrane methods. Science Direct, Springer Link, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, ProQuest and Network Digital Library databases were searched between 2000 and 2018 up to February 2018. The studies chosen conformed to PICOS inclusion and exclusion criteria. The risk of bias was assessed using the Cochrane risk of bias tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used in reporting the study. RESULTS: Twenty-four studies with a total of 6773 study participants met the inclusion criteria. It was found that telephone call interventions were the most commonly used, text message interventions came second with seven studies, telephone calls in combination with messages were used in four studies and telemonitoring was used in two studies. Compared to routine care, telehealth interventions had moderate significant effects in reducing waist circumference, total cholesterol and triglyceride, improving medication adherence and physical activity, and had small significant effects in reducing blood pressure and smoking cessation. No significant publication bias was found in the main outcomes. CONCLUSION: Results showed that the telehealth interventions yielded positive outcomes in lifestyle changes for coronary artery disease. Therefore, telehealth interventions can be used for effective secondary prevention by health professionals who care for individuals with coronary artery disease. Additionally, this study will provide guidance for studies on the development of telehealth intervention.

Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention.

BACKGROUND: In recent years, new information has been acquired regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society, therefore, decided to issue an update to the Italian Pediatric Society guidelines published in 2010. METHODS: The search was conducted on Pubmed, and only those studies regarding the pediatric age alone, in English or Italian, published between January 1, 2010 and December 31, 2018, were included. Each study included in the review was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The quality of the systematic reviews was evaluated using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts. RESULTS: The importance of eliminating risk factors (passive smoking, environmental pollution, use of pacifier, obesity, limitation of day-care center attendance) and the promotion of breastfeeding and hygiene practices (nasal lavages) was confirmed. The importance of pneumococcal vaccination in the prevention of AOM was reiterated with regard to the prevention of both the first episode of AOM and recurrences. Grommets can be inserted in selected cases of recurrent AOM that did not respond to all other prevention strategies. Antibiotic prophylaxis is not recommended for the prevention of recurrent AOM, except in certain carefully selected cases. The use of complementary therapies, probiotics, xylitol and vitamin D is not recommended. CONCLUSIONS: The prevention of episodes of AOM requires the elimination of risk factors and pneumococcal and influenza vaccination. The use of other products such as probiotics and vitamin D is not supported by adequate evidence.

Editor's Choice - Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

Cost-Effectiveness of Adjuvant Trastuzumab Therapy for Early Breast Cancer in Asia: A Systematic Review.

OBJECTIVES: To systematically review and assess the quality of the economic evidence of adjuvant trastuzumab usage in early breast cancer in Asian countries. METHODS: Literature search was performed using 6 electronic databases (PubMed, Scopus, Ovid MEDLINE, EconLit, National Health Service Economic Evaluation Database, and ISI Web of Knowledge). The final search was performed in October 2018. All potential economic studies were then checked for eligibility. The reporting and methodological qualities of each study were independently assessed by 2 authors of this review, using the Consolidated Health Economic Evaluation Reporting Standards, Drummond, and Philips checklists. To compare the different currencies used in these studies, all costs were converted into US dollars (2016). RESULTS: A total of 6 studies were included; most of them were performed from the healthcare provider perspective. The incremental cost-effectiveness ratio for evaluation performed for a lifetime horizon were reported at $8573 and $20 816 per quality-adjusted life-year in 2 studies. The model outcome was generally sensitive to the changes in trastuzumab drug acquisition cost and discount rate, as well as its clinical effectiveness. For the quality assessment, all studies fulfilled more than 50% of the requirements in the Consolidated Health Economic Evaluation Reporting Standards, Drummond, and Philips checklists. CONCLUSIONS: Adjuvant trastuzumab therapy is considered a cost-effective option for early breast cancer in Asian countries including China, Iran, Japan, Singapore, and Taiwan. All studies were generally well conducted. Economic evaluations from the societal perspective, with inclusion of indirect and informal care costs, are warranted to facilitate informed decision making among policy makers.

Orthopedic surgeons' views on the osteoporosis care gap and potential solutions: survey results.

INTRODUCTION: Osteoporosis is often not recognized until one or more fractures occur, yet post-fracture screening remains uncommon. Orthopedic surgeons are well situated to address this care gap. Both a protocol-based approach and fracture liaison services (FLS) have been proposed. The present surveys assess orthopedists' attitudes to these alternative models for addressing this care gap. METHODS: Two digital surveys were sent to all orthopedic surgeons and orthopedic midlevel providers at a large level 1 trauma center 1.5 years apart. RESULTS: Thirty-six of 47 survey recipients (77%) responded to the first survey; all 55 recipients (100%) responded to the second. Respondents recognized the importance of osteoporosis care, the inadequacy of current measures, and the potential of orthopedic surgeons to help address this gap. Respondents reported regular encounters with fragility fracture patients but limited familiarity with core aspects of osteoporosis screening and treatment, especially pharmacotherapy. While some respondents (40%) reported willingness to attempt a protocol-based approach to addressing this care gap, many others expressed reservations (60%) and support for a FLS-based approach was much higher (95%). CONCLUSIONS: A fracture liaison service model best fits the observed attitudes of orthopedic surgeons at this level 1 trauma center relative to a protocol-based approach. Protocol-based approaches may be preferable in alternate settings.

Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis.

BACKGROUND: Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD. METHODS: Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months' follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.). RESULTS: In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= -0.26 mmol/l, 95% CI= -0.4 to -0.11, p <0.001), low-density lipoprotein (WMD= -0.28, 95% CI = -0.50 to -0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04]. CONCLUSIONS: Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.