Most guideline organizations lack explicit guidance in how to incorporate cost considerations.

OBJECTIVES: Resource use and cost (RUC) evidence is one of the factors that can be considered when formulating recommendations in clinical practice guidelines (CPGs). However, it is unclear how CPG developers incorporate this information. The purpose of this study was to identify available guidance from guideline organizations on how to incorporate RUC in CPGs. STUDY DESIGN AND SETTING: This is a methodological survey. We searched MEDLINE, the G-I-N library, the Cochrane Methodology Register, and gray literature from inception to 2017. We included the most recent version of guidance documents. We excluded those that only reported methodology for adapting, endorsing, or updating CPGs, and documents reporting methods followed in the development of one or more specific CPGs. RESULTS: We included 77 documents from 67 organizations. Fifty-nine organizations (88.1%) include information regarding RUC during the CPG development process. Fifty-five (82.1%) organizations report taking RUC into account when developing recommendations: 44 (65.7%) do this explicitly, 5 (7.5%) implicitly, and 6 (9.0%) explicitly as optional. Twelve of the 44 organizations that explicitly consider RUC (27.3%) provide guidance to identify, assess and use the RUC evidence when developing recommendations. Twenty-three consider RUC when moving from the evidence to recommendations (52.3%). Seventeen of the 44 (38.6%) recommend making qualitative judgments about whether the desirable effects of interventions were worth the associated costs. CONCLUSION: More explicit guidance is needed alongside tools to help CPGs developers incorporate RUC evidence when formulating recommendations. Our results may be of use for guideline developers to improve this guidance.

Systemic antibiotics for treating diabetic foot infections.

BACKGROUND: Foot infection is the most common cause of non-traumatic amputation in people with diabetes. Most diabetic foot infections (DFIs) require systemic antibiotic therapy and the initial choice is usually empirical. Although there are many antibiotics available, uncertainty exists about which is the best for treating DFIs. OBJECTIVES: To determine the effects and safety of systemic antibiotics in the treatment of DFIs compared with other systemic antibiotics, topical foot care or placebo. SEARCH METHODS: In April 2015 we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library); Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE, and EBSCO CINAHL. We also searched in the Database of Abstracts of Reviews of Effects (DARE; The Cochrane Library), the Health Technology Assessment database (HTA; The Cochrane Library), the National Health Service Economic Evaluation Database (NHS-EED; The Cochrane Library), unpublished literature in OpenSIGLE and ProQuest Dissertations and on-going trials registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the effects of systemic antibiotics (oral or parenteral) in people with a DFI. Primary outcomes were clinical resolution of the infection, time to its resolution, complications and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed the risk of bias, and extracted data. Risk ratios (RR) were estimated for dichotomous data and, when sufficient numbers of comparable trials were available, trials were pooled in a meta-analysis. MAIN RESULTS: We included 20 trials with 3791 participants. Studies were heterogenous in study design, population, antibiotic regimens, and outcomes. We grouped the sixteen different antibiotic agents studied into six categories: 1) anti-pseudomonal penicillins (three trials); 2) broad-spectrum penicillins (one trial); 3) cephalosporins (two trials); 4) carbapenems (four trials); 5) fluoroquinolones (six trials); 6) other antibiotics (four trials).Only 9 of the 20 trials protected against detection bias with blinded outcome assessment. Only one-third of the trials provided enough information to enable a judgement about whether the randomisation sequence was adequately concealed. Eighteen out of 20 trials received funding from pharmaceutical industry-sponsors.The included studies reported the following findings for clinical resolution of infection: there is evidence from one large trial at low risk of bias that patients receiving ertapenem with or without vancomycin are more likely to have resolution of their foot infection than those receiving tigecycline (RR 0.92, 95% confidence interval (CI) 0.85 to 0.99; 955 participants). It is unclear if there is a difference in rates of clinical resolution of infection between: 1) two alternative anti-pseudomonal penicillins (one trial); 2) an anti-pseudomonal penicillin and a broad-spectrum penicillin (one trial) or a carbapenem (one trial); 3) a broad-spectrum penicillin and a second-generation cephalosporin (one trial); 4) cephalosporins and other beta-lactam antibiotics (two trials); 5) carbapenems and anti-pseudomonal penicillins or broad-spectrum penicillins (four trials); 6) fluoroquinolones and anti-pseudomonal penicillins (four trials) or broad-spectrum penicillins (two trials); 7) daptomycin and vancomycin (one trial); 8) linezolid and a combination of aminopenicillins and beta-lactamase inhibitors (one trial); and 9) clindamycin and cephalexin (one trial).Carbapenems combined with anti-pseudomonal agents produced fewer adverse effects than anti-pseudomonal penicillins (RR 0.27, 95% CI 0.09 to 0.84; 1 trial). An additional trial did not find significant differences in the rate of adverse events between a carbapenem alone and an anti-pseudomonal penicillin, but the rate of diarrhoea was lower for participants treated with a carbapenem (RR 0.58, 95% CI 0.36 to 0.93; 1 trial). Daptomycin produced fewer adverse effects than vancomycin or other semi-synthetic penicillins (RR 0.61, 95%CI 0.39 to 0.94; 1 trial). Linezolid produced more adverse effects than ampicillin-sulbactam (RR 2.66; 95% CI 1.49 to 4.73; 1 trial), as did tigecycline compared to ertapenem with or without vancomycin (RR 1.47, 95% CI 1.34 to 1.60; 1 trial). There was no evidence of a difference in safety for the other comparisons. AUTHORS' CONCLUSIONS: The evidence for the relative effects of different systemic antibiotics for the treatment of foot infections in diabetes is very heterogeneous and generally at unclear or high risk of bias. Consequently it is not clear if any one systemic antibiotic treatment is better than others in resolving infection or in terms of safety. One non-inferiority trial suggested that ertapenem with or without vancomycin is more effective in achieving clinical resolution of infection than tigecycline. Otherwise the relative effects of different antibiotics are unclear. The quality of the evidence is low due to limitations in the design of the included trials and important differences between them in terms of the diversity of antibiotics assessed, duration of treatments, and time points at which outcomes were assessed. Any further studies in this area should have a blinded assessment of outcomes, use standardised criteria to classify severity of infection, define clear outcome measures, and establish the duration of treatment.

Efficacy and Safety of Needle Acupuncture for Treating Gynecologic and Obstetric Disorders: An Overview.

Background: Acupuncture is being used increasingly to treat gynecologic and obstetric disorders. Objective: The aim of this review was to determine the efficacy and safety of acupuncture for treating pelvic and low-back pain during pregnancy, pain during labor, primary dysmenorrhea, and menopausal symptoms. Design: This is an overview of systematic reviews (SRs) and randomized controlled trials (RCTs). Search strategy: A literature search was conducted, in July 2010, in MEDLINE,® the Cochrane Database of Systematic Reviews, CENTRAL, the Database of Abstracts of Reviews of Effects, and Tripdatabase. Selection criteria: Published SRs and RCTs found during the literature search were included as well as RCTs that were published after completion of the literature search. Analysis: Data from SRs and RCTs that provided quantitative information were pooled. Results: Eight SRs and nine RCTs were included. One SR and 4 RCTs showed that acupuncture reduced pelvic and low-back pain, compared to physiotherapy or usual prenatal care. Results were contradictory when interventions were compared with sham acupuncture. With respect to reduction of pain during labor, two SRs showed no differences between acupuncture and sham acupuncture. None of the three SRs included on primary dysmenorrhea produced conclusive results. Two SRs of studies on menopausal symptoms showed no differences between acupuncture and sham acupuncture. A meta-analysis of three additional RCTs identified a favorable effect of acupuncture for reducing frequency and intensity of hot flashes. Adverse effects were mild and infrequent. Conclusions: Evidence for the efficacy of needle acupuncture for treating the disorders evaluated remains inconclusive. The intervention showed promising results for reducing pelvic and back pain during pregnancy and climacteric vasomotor symptoms, although well-designed studies are needed to make the results more precise and reliable.

Medical students' perceptions and attitudes about family practice: a qualitative research synthesis.

BACKGROUND: During the last decade medical students from most Western countries have shown little interest in family practice. Understanding the factors that influence medical students to choose family medicine is crucial. OBJECTIVE: To systematically review and synthesize published evidence about medical students' attitudes and perceptions towards family practice. METHODS: A qualitative systematic review. The literature search was undertaken in July 2010 in PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Social Science Citation Index (SSCI), and ProQuest Dissertations & Theses. Two authors independently selected the studies for their inclusion and assessed their quality. The selected studies were thoroughly read. Key themes and categories were identified. A matrix was created for allowing the comparison of each theme across studies. RESULTS: Ten studies were finally included. Seven broad themes were identified across them: 1) Scope and context of practice was a broad theme comprising linked sub-themes: perception of a varied specialty, broad practice, holistic perspective and flexibility that allows having a family; 2) Lower interest or intellectually less challenging: treating common disease, repetitive, quasi administrative job; 3) Influence of role models, either positive and negative, and society: negative comments from other professionals, peers and family; 4) Lower prestige; 5) Poor remuneration; 6) Medical school influences, being important both the length and quality of the exposure; 7) Post graduate training, where the shorter duration and the lower intensity were perceived as positive aspects. After identifying these seven key themes, were also looked into patterns in the distribution of these themes among studies. CONCLUSIONS: Our qualitative review provides a comprehensive picture of medical students' attitudes towards family practice in the available literature. In general, although some students find family medicine appealing, it is regarded as a career of low interest and prestige. More research is needed on the influence of role models, medical school and post graduate training.