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.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus.

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

Artificial intelligence and automation of systematic reviews in women's health.

PURPOSE OF REVIEW: Evidence-based women's healthcare is underpinned by systematic reviews and guidelines. Generating an evidence synthesis to support guidance for clinical practice is a time-consuming and labour-intensive activity that delays transfer of research into practice. Artificial intelligence has the potential to rapidly collate, combine, and update high-quality medical evidence with accuracy and precision, and without bias. RECENT FINDINGS: This article describes the main fields of artificial intelligence with examples of its application to systematic reviews. These include the capabilities of processing natural language texts, retrieving information, reasoning, and learning. The complementarity and interconnection of the various artificial intelligence techniques can be harnessed to solve difficult problems in automation of reviews. Computer science can advance evidence-based medicine through development, testing, and refinement of artificial intelligence tools to deploy automation, creating 'living' evidence syntheses. SUMMARY: Groundbreaking, high-quality, and impactful artificial intelligence will accelerate the transfer of individual research studies seamlessly into evidence syntheses for contemporaneously improving the quality of healthcare.

Barriers and facilitators to use of a clinical evidence technology in the management of skin problems in primary care: insights from mixed methods.

OBJECTIVE: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider's perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. METHODS: Using a convergent mixed methods design, the authors had PCPs complete a post-trial survey and participate in interviews about using the CET for managing patients' skin problems. Data from both methods were integrated. RESULTS: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. CONCLUSION: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management.

Survey of Infection Control Precautions for Patients with Severe Combined Immune Deficiency.

Severe combined immune deficiency (SCID) is caused by an array of genetic disorders resulting in a diminished adaptive immune system due to impaired T lymphocytes. In these patients, active infection at the time of hematopoietic transplantation has been shown to increase morbidity and mortality. To prevent transmission of infections in SCID patients, standardized infection control precautions should be implemented. An online survey regarding SCID-specific protocols was distributed through several immunodeficiency organizations. Seventy-three responses were obtained, with the majority (55%) of responses from the USA, 15% from Canada, and the remainder from 12 other countries. Only 50% of respondents had a SCID-specific infection control protocol at their center, and while a majority of these centers had training for physicians, a small minority had training for other healthcare workers such as nursing and housekeeping staff. Significant variability of infection control practices, such as in-patient precautions, required personal protective equipment (PPE), diet restrictions, visitor precautions and discharge criteria, was found between different treatment centers. There is a paucity of evidence-based data regarding the safest environment to prevent infection in SCID patients. Institutional protocols may have significant impact on infection risk, survival, family well-being, child development and cost of care. From these results, it is evident that further multi-center research is required to determine the safest and healthiest environment for these children, so that evidence-based infection control protocols for patients with SCID can be developed.

Smart Trauma: Improving the Delivery of Evidence-Based Trauma Care.

BACKGROUND: Mobile technology can aid in healthcare decision-making at the point of care. We created a Web-based trauma-specific smartphone application containing links to local protocols and national organization guidelines for trauma providers. We hypothesized that smartphone access to these guidelines would facilitate application of knowledge in a timely fashion. MATERIALS AND METHODS: Trauma providers were randomized to have or not have access to their smartphone during a timed, 10-question examination of trauma scenarios based on Eastern Association for the Surgery of Trauma, Western Trauma Association, and local protocols. Participants were then surveyed regarding their experience with the application. Groups were compared based on time with completion and percentage of correct answers. Subgroup analyses were completed to assess the utility of the application. RESULTS: Of 30 participants, 16 were randomized to smartphone use. Smartphone users took longer to complete the examination than nonusers (9:18 versus 6:36, P = 0.007) but answered a greater proportion of questions correctly (50% versus 40%, P = 0.159). Smartphone users had a higher percentage correct for Eastern Association for the Surgery of Trauma and Western Trauma Association protocol-based questions (78% versus 52%, P = 0.027; 70% versus 39%, P = 0.011), but no difference for local protocol-based questions (29% versus 37%, P = 0.48). Smartphone users who reported recent application use had the longest time to completion (11:44, P = 0.023) but the highest percentage correct (60%, P = 0.03). CONCLUSIONS: Smartphone use among those familiar with our trauma application resulted in the highest percentage correct but increased times to completion. The application interface should be streamlined, and providers educated to improve usage and reduce time to access information.

Use of Convexity in Ostomy Care: Results of an International Consensus Meeting.

Ostomy skin barriers that incorporate a convexity feature have been available in the marketplace for decades, but limited resources are available to guide clinicians in selection and use of convex products. Given the widespread use of convexity, and the need to provide practical guidelines for appropriate use of pouching systems with convex features, an international consensus panel was convened to provide consensus-based guidance for this aspect of ostomy practice. Panelists were provided with a summary of relevant literature in advance of the meeting; these articles were used to generate and reach consensus on 26 statements during a 1-day meeting. Consensus was achieved when 80% of panelists agreed on a statement using an anonymous electronic response system. The 26 statements provide guidance for convex product characteristics, patient assessment, convexity use, and outcomes.

[Clinical guidelines using the GRADE system (Grading of Recommendations Assessment, Development and Evaluation)]. / Cómo interpretar guías de práctica clínica elaboradas con metodología GRADE.

The Ministry of Health of Chile, aiming to improve the quality of clinical practice guidelines, gradually incorporated the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) to develop evidence based recommendations. This system summarizes and evaluates the certainty of the available evidence. It moves from evidence to decision in a systematic and transparent manner, based on four main dimensions: balance between benefits and harms, certainty of evidence, patient's values and preferences and use of resources. The GRADE system produces strong and conditional recommendations. Strong recommendations provide confidence that the favorable consequences of an intervention clearly outweigh the adverse consequences, or vice versa. These recommendations apply to a broad range of patients and circumstances. Conditional recommendations, however, indicate that there is a close balance between favorable and unfavorable consequences of the intervention, there is uncertainty in the magnitude of benefits or adverse effects, there is uncertainty or variability in values and preferences of individuals or costs are not justified. These recommendations apply to many patients, but not all of them: ideally they should be discussed with each person. To achieve a better implementation of the recommendations made with GRADE methodology, health professionals should know the meaning of strong and conditional recommendations and they should be able to critically assess of them.

A mapping review of the literature on UK-focused health and social care databases.

BACKGROUND: Bibliographic databases are a day-to-day tool of the researcher: they offer the researcher easy and organised access to knowledge, but how much is actually known about the databases on offer? The focus of this paper is UK health and social care databases. These databases are often small, specialised by topic, and provide a complementary literature to the large, international databases. There is, however, good evidence that these databases are overlooked in systematic reviews, perhaps because little is known about what they can offer. OBJECTIVES: To systematically locate and map, published and unpublished literature on the key UK health and social care bibliographic databases. METHODS: Systematic searching and mapping. RESULTS: Two hundred and forty-two items were identified which specifically related to the 24 of the 34 databases under review. CONCLUSION: There is little published or unpublished literature specifically analysing the key UK health and social care databases. Since several UK databases have closed, others are at risk, and some are overlooked in reviews, better information is required to enhance our knowledge. Further research on UK health and social care databases is required. This paper suggests the need to develop the evidence base through a series of case studies on each of the databases.

The brief aggression questionnaire: psychometric and behavioral evidence for an efficient measure of trait aggression.

A key problem facing aggression research is how to measure individual differences in aggression accurately and efficiently without sacrificing reliability or validity. Researchers are increasingly demanding brief measures of aggression for use in applied settings, field studies, pretest screening, longitudinal, and daily diary studies. The authors selected the three highest loading items from each of the Aggression Questionnaire's (Buss & Perry, 1992) four subscales--Physical Aggression, Verbal Aggression, anger, and hostility--and developed an efficient 12-item measure of aggression--the Brief Aggression Questionnaire (BAQ). Across five studies (N = 3,996), the BAQ showed theoretically consistent patterns of convergent and discriminant validity with other self-report measures, consistent four-factor structures using factor analyses, adequate recovery of information using item response theory methods, stable test-retest reliability, and convergent validity with behavioral measures of aggression. The authors discuss the reliability, validity, and efficiency of the BAQ, along with its many potential applications.

Evidence-based assessment of childhood injuries and physical risk-taking behaviors.

OBJECTIVE: To offer a critical evidence-based review and summary of assessment methods of childhood injuries and physical risk-taking behaviors. METHODS: A literature review was conducted to identify methodologies for assessing injury events and physical risk-taking behaviors. Methodologies reviewed included self- or parent-report scales, behavioral observations, and participant event monitoring. We classified methodologies according to published criteria of "well-established," "approaching well-established," or "promising." RESULTS: 7 methodologies were classified as "well-established", 9 were classified as "approaching well-established", and 8 were classified as "promising." CONCLUSIONS: Several approaches to assessing injuries or physical risk-taking behaviors have strong psychometric properties. Opportunities for further psychometric validation of techniques are noted. It is hoped that this review inspires researchers throughout the fields of pediatric and clinical child psychology to adopt assessments of injury and physical risk-taking in their ongoing research efforts.

Evidence-informed recommendations for constructing and disseminating messages supplementing the new Canadian Physical Activity Guidelines.

BACKGROUND: Few validated guidelines exist for developing messages in health promotion practice. In clinical practice, the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument is the international gold standard for guideline assessment, development, and reporting. In a case study format, this paper describes the application of the AGREE II principles to guide the development of health promotion guidelines for constructing messages to supplement the new Canadian Physical Activity Guidelines (CPAG) released in 2011. METHODS: The AGREE II items were modified to suit the objectives of developing messages that (1) clarify key components of the new CPAG and (2) motivate Canadians to meet the CPAG. The adapted AGREE II Instrument was used as a systematic guide for the recommendation development process. Over a two-day meeting, five workgroups (one for each CPAG - child, youth, adult, older adult - and one overarching group) of five to six experts (including behavior change, messaging, and exercise physiology researchers, key stakeholders, and end users) reviewed and discussed evidence for creating and targeting messages to supplement the new CPAG. Recommendations were summarized and reviewed by workgroup experts. The recommendations were pilot tested among end users and then finalized by the workgroup. RESULTS: The AGREE II was a useful tool in guiding the development of evidence-based specific recommendations for constructing and disseminating messages that supplement and increase awareness of the new CPAG (child, youth, adults, and older adults). The process also led to the development of sample messages and provision of a rationale alongside the recommendations. CONCLUSIONS: To our knowledge, these are the first set of evidence-informed recommendations for constructing and disseminating messages supplementing physical activity guidelines. This project also represents the first application of international standards for guideline development (i.e., AGREE II) to the creation of practical recommendations specifically aimed to inform health promotion and public health practice. The messaging recommendations have the potential to increase the public health impact of evidence-based guidelines.

Disease diagnostic coding to facilitate evidence-based medicine: current and future perspectives.

Technologic advances in information management have rapidly changed laboratory testing and the practice of veterinary medicine. Timely and strategic sampling, same-day assays, and 24-h access to laboratory results allow for rapid implementation of intervention and treatment protocols. Although agent detection and monitoring systems have progressed, and wider tracking of diseases across veterinary diagnostic laboratories exists, such as by the National Animal Health Laboratory Network (NAHLN), the distinction between detection of agent and manifestation of disease is critical to improved disease management. The implementation of a consistent, intuitive, and useful disease diagnosis coding system, specific for veterinary medicine and applicable to multiple animal species within and between veterinary diagnostic laboratories, is the first phase of disease data aggregation. Feedback loops for continuous improvement that could aggregate existing clinical and laboratory databases to improve the value and applications of diagnostic processes and clinical interventions, with interactive capabilities between clinicians and diagnosticians, and that differentiate disease causation from mere agent detection, remain incomplete. Creating an interface that allows aggregation of existing data from clinicians, including final diagnosis, interventions, or treatments applied, and measures of outcomes, is the second phase. Prototypes for stakeholder cooperation, collaboration, and beta testing of this vision are in development and becoming a reality. We focus here on how such a system is being developed and utilized at the Iowa State University Veterinary Diagnostic Laboratory to facilitate evidence-based medicine and utilize diagnostic coding for continuous improvement of animal health and welfare.

The study on the clinical effectiveness and safety of traditional Chinese medicine acupoint catgut embedding guided by musculoskeletal ultrasound in the treatment of nerve root sciatica: A protocol for systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Nerve root sciatica (NRS) is a common orthopedic disease, which usually occurs between 20 and 40 years of age, and the incidence rate is increasing year by year and is being younger. The disease has no special effect of treatment, clinically generally taking the symptomatic treatment, such as taking short-term glucocorticoids, sedatives, analgesics, and so on. Long-term use of drugs will adversely affect the patient's gastrointestinal tract, liver, and kidney function. The surgical treatment has a high risk of surgery, high cost, side effects, and other problems, so the choice of treatment method has always been a difficult problem in clinical and scientific research. The study shows that 90% of patients with sciatica can be cured by non-surgical treatment, so conservative therapy is often used in the treatment of sciatica, traditional Chinese medicine treatment methods in the treatment of NRS has been widely used, which has achieved good results, but there is no evidence of evidence-based medicine. Therefore, this study uses systematic evaluation to conduct the scientific evaluation of the clinical effectiveness and safety of traditional Chinese medicine acupoint catgut embedding guided by musculoskeletal ultrasound in the treatment of NRS, and provide evidence-based medical evidence support for the treatment of NRS. METHODS: Using the computer to retrieve the PubMed, ScienceDirect, Web of Science, Embase, Cochrane Library, CNKI, VIP, WANFANG Database, and CBM. Using the subject words and terminology words to retrieve the Chinese-English database and retrieve a randomized controlled study on the clinical effectiveness and safety of traditional Chinese medicine acupoint catgut embedding guided by musculoskeletal ultrasound in the treatment of NRS, and the range of search time is January 1990 to January 2021. The searched literature is screened and evaluated by two researchers respectively according to the inclusion and exclusion criteria. If there is disagreement, discussing it with the third researcher to determine the final inclusion of the literature. Using the RevMan 5.3 software to conduct the meta-analysis. RESULTS: This study will compare the effectiveness and safety of traditional Chinese medicine acupoint catgut embedding guided by musculoskeletal ultrasound in the treatment of NRS. CONCLUSION: The results of this study will be published in internationally influential academic journals to provide evidence-based medical evidence for the clinical effectiveness and safety of traditional Chinese medicine acupoint catgut embedding in the treatment of NRS. ETHICS AND DISSEMINATION: This study does not involve specific patients, and all research data comes from publicly available professional literature, so an ethics committee is not required to conduct an ethical review and approval of the study. OSF REGISTRATION NUMBER: DOI 10.17605/OSF.IO/Q492E.

Management of Acute and Traumatic Wounds With Negative-Pressure Wound Therapy With Instillation and Dwell Time.

BACKGROUND: A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds. METHODS: A systematic review was performed analyzing articles from major clinical databases. Only clinical studies ≥10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included. RESULTS: One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported. CONCLUSION: NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.

Screening and case finding tools for the detection of dementia. Part I: evidence-based meta-analysis of multidomain tests.

AIM: To evaluate the diagnostic accuracy of all brief multidomain alternatives to the Mini-Mental State Examination (MMSE) in the detection of dementia. METHODS: A literature search, critical appraisal, and meta-analysis were conducted of robust diagnostic validity studies involving cognitive batteries. Twenty-nine distinct brief batteries were tested in 44 large-scale analyses. Twenty studies took place in specialist settings (11 in memory clinics and 9 in secondary care), ten studies were conducted in primary care, and 14 in the community. RESULTS: In community settings with a low prevalence of dementia, short screening methods of no more than 10 minutes had an overall sensitivity of 72.0% (95% confidence interval [CI] = 60.4%-82.3%) and a specificity of 88.2% (95% CI = 83.0%-92.5%). The optimal individual tests were the Telephonic interview based on MSQ, Category fluency/Memory impairment screen-Telephonic interview and 6 item Cognitive Impairment Test (6-CIT), but data were limited by the absence of multiple independent confirmation for any individual test. In primary care where the prevalence of dementia is usually modest, the optimal individual tools were the Abbreviated mental test score/Mental status questionnaire (MSQ), and Prueba cognitive de leganes (PCL). Furthermore, the Abbreviated mental test score (AMTS) was superior to the MMSE for case finding, but for screening the MMSE was optimal. If length is not a major consideration, the MMSE may remain the best tool for primary care clinicians who want to rule in and rule out a diagnosis. In specialist settings where the prevalence of dementia is often high, the optimal individual tools were the DEMTECT, Montreal cognitive assessment (MOCA), Memory Alteration test, and MINI-COG. Two tools were potentially superior to the MMSE for rule in and rule out, namely the 6-CIT and MINI-COG. Only four analyses looked specifically at accuracy in early-stage dementia, and each showed at least equivalent diagnostic accuracy, suggesting these methods might be applicable to early identification. CONCLUSION: A large number of alternatives to the MMSE have now been validated in large samples with favorable rule-in and rule-out accuracy. Evidence to date suggests for those wishing to use brief battery tests then the original MMSE or the AMTS should be considered in primary care and either the 6-CIT or the MINI-COG should be considered in specialist settings.

Evidence-based guidelines in the evaluation of work disability: an international survey and a comparison of quality of development.

BACKGROUND: In social insurance, the evaluation of work disability is becoming stricter as priority is given to the resumption of work, which calls for a guarantee of quality for these evaluations. Evidence-based guidelines have become a major instrument in the quality control of health care, and the quality of these guidelines' development can be assessed using the AGREE instrument. In social insurance medicine, such guidelines are relatively new. We were interested to know what guidelines have been developed to support the medical evaluation of work disability and the quality of these guidelines. METHODS: Five European countries that were reported to use guidelines were approached, using a recent inventory of evaluations of work disability in Europe. We focused on guidelines that are disease-oriented and formally prescribed in social insurance medicine. Using the AGREE instrument, these guidelines were appraised by two researchers. We asked two experts involved in guideline development to indicate if they agreed with our results and to provide explanations for insufficient scores. RESULTS: We found six German and sixteen Dutch sets of disease-oriented guidelines in official use. The AGREE instrument was applicable, requiring minor adaptations. The appraisers reached consensus on all items. Each guideline scored well on 'scope and purpose' and 'clarity and presentation'. The guidelines scored moderately on 'stakeholder involvement' in the Netherlands, but insufficiently in Germany, due mainly to the limited involvement of patients' representatives in this country. All guidelines had low scores on 'rigour of development', which was due partly to a lack of documentation and of existing evidence. 'Editorial independence' and 'applicability' had low scores in both countries as a result of how the production was organised. CONCLUSION: Disease-oriented guidelines in social insurance medicine for the evaluation of work disability are a recent phenomenon, so far restricted to Germany and the Netherlands. The AGREE instrument is suitably applicable to assess the quality of guideline development in social insurance medicine, but some of the scoring rules need to be adapted to the context of social insurance. Existing guidelines do not meet the AGREE criteria to a sufficient level. The way patients' representatives can be involved needs further discussion. The guidelines would profit from more specific recommendations and, for providing evidence, more research is needed on the functional capacity of people with disabilities.