Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: relevance, need, and processes for development.

Guidelines or recommendations help to provide uniform standards in medical practice. The development of guidelines requires adherence to pre-defined norms prescribed by different international organizations such as the European League against Rheumatism (EULAR). We searched Pubmed and LILACS to identify published papers in five major rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, osteoarthritis, and scleroderma) from different countries based on their economic prosperity and could find a lack of published literature from most economically weaker regions. Similarly, published guidelines in these rheumatic diseases were sparse from Asia and Africa, which are economically developed to a lesser extent than other regions of the world. Considering differing economic realities driving patient care in different regions of the world, unique challenges in certain geographic areas such as musculoskeletal manifestations of infectious diseases like leprosy and tuberculosis, as well as distinct risk of malignancies and other comorbid conditions, National Rheumatology societies should work towards developing more guidelines for rheumatic diseases from regions such as Asia and Africa, while following strictly the prescribed norms for the same. With a paucity of guidelines for such regions currently, an alternative (although less preferable) suggestion would be that major international societies, whose guidelines are widely read and followed the world over, should consider inputs from experts from diverse regions of the world while developing these guidelines.

Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. AIM: The ideal therapy of Stevens-Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. METHODS: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens-Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as "guidelines," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "corticosteroids," "intravenous immunoglobulin," "cyclosporine" and "management." The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. RESULTS: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. RECOMMENDATIONS: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

Guidelines on the use of finasteride in androgenetic alopecia.

BACKGROUND: Finasteride is a widely used drug in dermatology for the treatment of androgenetic alopecia. There are many reports of associated sexual side effects. This article reviews the use of once-daily 1 mg finasteride in androgenetic alopecia and its associated sexual adverse effects. METHODS: A literature search was performed to collect data on the use of finasteride in male pattern baldness. Relevant literature published till March 2014 was obtained from MEDLINE, EMBASE, CINAHL, Cochrane registers and LILACS. The keywords "finasteride", "male pattern baldness" and "androgenetic alopecia" were used for literature search. Similarly, a search was done for finasteride in female pattern hair loss with keywords "female pattern baldness", "finasteride" and "female pattern alopecia". All systematic reviews, meta-analyses, national guidelines, randomized controlled trials, prospective open label studies and retrospective case series in the English literature were reviewed. RESULTS: Two hundred sixty two studies were evaluated, twelve of which fulfilled the inclusion criteria. CONCLUSIONS AND RECOMMENDATIONS: Current evidence on the safety of finasteride indicates that it is safe but there is growing concern about its sexual side effects. In view of this, proper information should be provided to patients prior to starting treatment (Level of recommendation 1+, Grade of recommendation B). The reported sexual side effects are few and reverse with stoppage of the drug (Grade of recommendation B) but further studies are required.

A Delphi exercise to refine the WHO three-point disability grading system for leprosy, and to develop guidelines to promote greater accuracy and reliability of WHO disability recording.

A Delphi Exercise was undertaken with two objectives: (1) To ascertain whether operational definitions for WHO Disability Grading could be formulated by consensus. (2) To develop a set of simple guidelines based on those definitions for the guidance of health workers. Fifteen people with general expertise in prevention of disability due to leprosy were invited to participate as Delphi panel members, twelve responded positively. Eight issues that commonly cause confusion provided foci for the exercise. Operational definitions aimed at resolving those issues were developed by consensus. Simple guidelines for health workers, based on those definitions were also created and supported by consensus. This paper presents the process followed and the outcomes gained from the endeavour.

Standard guidelines for care: sclerotherapy in dermatology.

DEFINITION: Sclerotherapy is defined as the targeted elimination of small vessels, varicose veins and vascular anomalies by the injection of a sclerosant. The aim of sclerotherapy is to damage the vessel wall and transform it into a fibrous cord that cannot be recanalized. It is a simple, cost-effective, efficacious and esthetically acceptable modality for both therapeutic and esthetic purposes. INDICATIONS: Therapeutic indications include varicose veins and vascular malformations. Esthetic indications include telangiectasias and reticular veins. In the management of varicose veins, it may need to be combined with other surgical methods of treatment, such as ligation of the saphenofemoral junction, stab ligation of perforators and stripping. A surgical opinion may be necessary. METHODOLOGY: A thorough knowledge of the anatomy and physiology of the venous system of the legs, basic principles of venous insufficiency, methods of diagnosis and, in addition, uses, mechanisms of action and complications of sclerosing agents and proper compression techniques are important pre-requisites to successful sclerotherapy. Although various sclerosing agents are available, polidoconal and sodium tetradecyl sulfate are most commonly used. More recently, these sclerosants have been used in microfoam form for increased efficacy. The basic principle of a successful sclerotherapy technique is the use of an optimal volume and concentration of the sclerosant according to the size of the vessel. The sclerosant is injected carefully into the vessel and compression is applied. CONTRAINDICATIONS: Contraindications include superficial and deep venous thrombosis, sapheno-femoral junction incompetence, pregnancy, myocardial decompensation, migraine, hypercoagulable state, serious systemic illness, dependency edema, immobility, arterial disease, diabetes mellitus and allergic reactions to sclerosants. COMPLICATIONS: While sclerotherapy is usually a safe procedure, complications may occur due to inappropriate patient selection or improper injection techniques. The complications may be acute or delayed. Complications include hyperpigmentation, matting, local urticaria, cutaneous necrosis, microthrombi, accidental intra-arterial injection, phlebitis, deep vein thrombosis, thromboembolism, scintillating scotomas, nerve damage and allergic reactions. PHYSICIAN QUALIFICATION: Sclerotherapy may be administered by a surgeon or dermatologist who has acquired adequate training during post-graduation or through recognized fellowships and workshops dedicated to sclerotherapy. He should have an adequate knowledge of the anatomy of the venous system, be able to diagnose and manage venous disease and its associated consequences as well as possess the necessary skills to perform the procedures, understand the appropriate indications and limitations, technique modifications and management of the potential adverse sequelae associated with sclerotherapy and also understand the pharmacology of the sclerosing solutions. FACILITY: The procedure may be performed in the physician's procedure room.

A Delphi consensus on criteria for contraindications, assessment indicators and expected outcomes related to tibialis posterior transfer surgery.

A team of experts in the field of reconstructive surgery for leprosy-affected people was identified. Using the Delphi method, an exercise was undertaken to ascertain whether a consensus on essential criteria and indicators for Tibialis Posterior Transfer (TPT) could be reached among the team. This paper describes the Delphi Exercise, giving results at each stage of consensus development. The final outcome was that essential criteria, including contraindications for surgery, pre- and post- operative assessments and expected outcomes, were agreed. The criteria are presented with recommendations.

'Client satisfaction'--guidelines for assessing the quality of leprosy services from the clients' perspective.

In order to ensure that leprosy patients are detected and treated adequately, it is essential that they are satisfied with the services provided. Their satisfaction can be analysed by assessing the quality of the services from a client perspective. This will give crucial information for the identification of strengths and weaknesses of leprosy services, e.g. in areas such as health seeking behaviour and regularity of treatment. It necessitates, however, that special attention is given to clients' opinions and ideas, both of which are rarely included in reviews and evaluations of leprosy programmes. Hence, an initiative was taken to formulate guidelines for the conducting of a study on client satisfaction. These guidelines were pre-tested in two countries, Nepal and Brazil. The development and contents of these guidelines are highlighted and discussed in this paper.