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1.
BMJ ; 367: l5887, 2019 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690574

RESUMO

Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.


Assuntos
Complicações do Diabetes/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemia/epidemiologia , Hipoglicemiantes/administração & dosagem , Qualidade de Vida , Glicemia/análise , Glicemia/efeitos dos fármacos , Complicações do Diabetes/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Hiperglicemia/sangue , Hiperglicemia/tratamento farmacológico , Hipoglicemia/induzido quimicamente , Hipoglicemiantes/efeitos adversos , Incidência , Metanálise como Assunto , Assistência Centrada no Paciente/métodos , Assistência Centrada no Paciente/normas , Guias de Prática Clínica como Assunto , Revisão Sistemática como Assunto , Resultado do Tratamento
3.
Am J Orthod Dentofacial Orthop ; 156(4): 442-452.e12, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31582116

RESUMO

INTRODUCTION: This study evaluated and compared the completeness of reporting of abstracts of orthodontics systematic reviews before and after the publication of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Abstracts Checklist (PRISMA-A). METHODS: Abstracts of systematic reviews and meta-analyses in orthodontics published in PubMed, Latin American and Caribbean Health Sciences Literature, and the Cochrane Database of Systematic Reviews databases before March 23, 2018, that met the predefined inclusion and exclusion criteria, were evaluated using the 12 items of PRISMA-A, scoring each item from 0 to 2. Abstracts were classified into 2 groups: before and after publication of the PRISMA-A checklist. Three calibrated evaluators (intraclass correlation coefficient and kappa > 0.8) assessed the scores for compliance with the checklist. The number of authors, country of affiliation of the first author, performance of meta-analysis, and topic of the article were recorded. A regression analysis was performed to assess the associations between abstract characteristics and the PRISMA-A scores. RESULTS: Of 1034 abstracts evaluated, 389 were included in the analysis. The mean PRISMA-A score was 53.39 (95% CI, 51.83-54.96). The overall score for studies published after the publication of the checklist was significantly higher than for studies published before (P ≤ 0.0001). The components returning significantly higher scores after publication of PRISMA-A were title (P = 0.024), information from databases (P = 0.026), risk of bias (P ≤ 0.0001), included studies (P ≤ 0.0001), synthesis of results (P ≤ 0.0001), interpretation of results (P = 0.035), financing and conflict of interest (P ≤ 0.0001), and registration (P ≤ 0.0001). These results showed the positive effect of PRISMA-A had on the quality of reporting of orthodontics systematic reviews. Nevertheless, the poor adherence revealed that there is still need for improvement in the quality of abstract reporting. CONCLUSIONS: The quality of reporting of abstracts of orthodontic systematic reviews and meta-analyses increased after the introduction of PRISMA-A.


Assuntos
Medicina Baseada em Evidências/normas , Ortodontia/normas , Publicações Periódicas como Assunto/normas , Editoração/normas , Revisão Sistemática como Assunto , Bibliometria , Lista de Checagem , Humanos , Controle de Qualidade
4.
BMC Health Serv Res ; 19(1): 638, 2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31488146

RESUMO

BACKGROUND: The Choosing Wisely campaign has spread to many countries. Methods for developing recommendations are inconsistent. We describe our process of developing such recommendations from a comprehensive national set of clinical practice guidelines (Current Care, CC) and the results of a one-year Choosing Wisely Finland project. METHODS: Two of the authors drafted the quality and process criteria for all the Choosing Wisely Finland recommendations. The quality criteria were relevance, feasibility, evidence-based and strength. These were discussed in editors' meetings and subsequently revised. Two different processes for developing recommendations within national clinical practice guidelines were designed and piloted (processes A and B). Process A was based on a published guideline. The recommendations are drafted by an editor and revised and approved by the guideline development group. In process B the development of the recommendations is integrated with guideline production or update. Choosing Wisely recommendations were then drafted for half of the published CC Guidelines. An additional process (process C) was designed for producing independent recommendations outside a guideline. RESULTS: At least one Choosing Wisely recommendation could be identified from 39 out of 52 reviewed guidelines. Of the 106 recommendations drafted, 62 (58%) were accepted for publication. The main reasons for rejection were inability to give a strong recommendation (n = 18, 41%) and insufficient relevance (n = 14, 32%). Two thirds (n = 41, 66%) of the published recommendations were based on high to moderate level of evidence, and 18% (n = 11) on low or very low level of evidence, whereas for the rest, the quality of evidence was not critically appraised. CONCLUSIONS: Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations.


Assuntos
Tomada de Decisão Clínica , Medicina Baseada em Evidências/normas , Guias de Prática Clínica como Assunto , Finlândia , Implementação de Plano de Saúde , Humanos , Sobremedicalização/prevenção & controle , Melhoria de Qualidade
5.
Z Evid Fortbild Qual Gesundhwes ; 144-145: 90-99, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31399391

RESUMO

BACKGROUND: Guideline developers can: (1) adopt existing recommendations from others; (2) adapt existing recommendations to their own context; or (3) create recommendations de novo. Monetary and nonmonetary resources, credibility, maximization of uptake, as well as logical arguments should guide the choice of the approach and processes. OBJECTIVES: To describe a potentially efficient model for guideline production based on adoption, adaptation, and/or de novo development of recommendations utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks. STUDY DESIGN AND SETTING: We applied the model in a new national guideline program producing 22 practice guidelines. We searched for relevant evidence that informs the direction and strength of a recommendation. We then produced GRADE EtDs for guideline panels to develop recommendations. RESULTS: In two waves, a total of 80 EtD frameworks was produced approximately 4 months and 146 EtDs in about 6 months. Use of the EtD frameworks allowed panel members to understand judgments of other guideline groups about the criteria that bear on guideline recommendations and then make their own judgments about those criteria in a systematic approach. CONCLUSION: The "GRADE-ADOLOPMENT" approach to guideline production combines adoption, adaptation, and, as needed, de novo development of recommendations. If guideline developers apply EtD criteria more widely and make their work publically available, this approach should prove even more useful.


Assuntos
Tomada de Decisões , Medicina Baseada em Evidências , Guias de Prática Clínica como Assunto , Técnicas de Apoio para a Decisão , Assistência à Saúde , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Alemanha , Recursos em Saúde , Humanos , Guias de Prática Clínica como Assunto/normas
6.
Gastroenterology ; 157(3): 859-880, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31351880

RESUMO

BACKGROUND & AIMS: The evaluation of patients with chronic watery diarrhea represents a diagnostic challenge for clinicians because organic causes, including inflammatory bowel disease, microscopic colitis, and chronic infection, must be differentiated from functional diarrhea and diarrhea-predominant irritable bowel syndrome. The purpose of this review is to summarize the available evidence on the usefulness of diagnostic tests in such patients. METHODS: We searched MEDLINE and EMBASE via OVID, from 1978 until April 2017. We included diagnostic test accuracy studies reporting on the use of fecal and blood tests for the evaluation of adult patients with functional diarrhea, including irritable bowel syndrome. We assessed the risk of bias of included studies using a modified version of the Quality Assessment of Diagnostic Accuracy Studies II, and the certainty in the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. We calculated pooled sensitivity and specificity, and the proportion of patients with true and false positive and negative results. We evaluated the following tests: erythrocyte sedimentation rate, C-reactive protein, fecal lactoferrin, fecal calprotectin, serologic tests for celiac disease, tests for bile acid diarrhea, the commercially available version of anti-cytolethal distending toxin B and anti-vinculin antibodies, and tests for Giardia infection. We did not evaluate breath tests for small intestinal bacterial overgrowth, as they are not part of a standard diarrhea workup. RESULTS: Thirty-eight studies proved eligible to evaluate 1 or more of these tests. Erythrocyte sedimentation rate and C-reactive protein were similar at discriminating organic from functional disease, with sensitivity and specificity, respectively, of 0.54-0.78 and 0.46-0.95 for erythrocyte sedimentation rate and 0.73 and 0.78 for C-reactive protein. Among fecal tests, fecal calprotectin in a range of 50-60 µg/g (pooled sensitivity 0.81; 95% confidence interval [CI], 0.75-0.86; pooled specificity 0.87; 95% CI, 0.78-0.92) and fecal lactoferrin in a range of 4.0-7.25 µg/g (pooled sensitivity 0.79; 95% CI, 0.73-0.84; pooled specificity 0.93; 95%CI 0.63-0.99) presented the lowest proportion of false-negative results (low certainty in the evidence). Among tests for celiac disease, IgA tissue transglutaminase presented the best diagnostic test accuracy (sensitivity range, 0.79-0.99; specificity range, 0.90-0.99) with moderate certainty in the evidence. Among tests for bile acid diarrhea, the 75selenium homotaurocholic acid test performed better than serum fibroblast growth factor 19 and 7α-hydroxy-4-cholesten-3-one, but is not available in the United States. There was insufficient evidence to recommend serologic tests for irritable bowel syndrome at this time. There are several good diagnostic tests for Giardia infection. CONCLUSIONS: Moderate to low certainty in the evidence indicates that available fecal and blood tests may play a role in the diagnostic workup of adult patients with functional diarrhea. At the moment, no tests are available to reliably rule in irritable bowel syndrome.


Assuntos
Técnicas de Diagnóstico do Sistema Digestório/normas , Diarreia/diagnóstico , Gastroenterologia/normas , Síndrome do Intestino Irritável/diagnóstico , Doença Crônica , Diagnóstico Diferencial , Diarreia/etiologia , Diarreia/fisiopatologia , Diarreia/terapia , Medicina Baseada em Evidências/normas , Humanos , Síndrome do Intestino Irritável/complicações , Síndrome do Intestino Irritável/fisiopatologia , Síndrome do Intestino Irritável/terapia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sociedades Médicas , Fatores de Tempo
7.
Br J Anaesth ; 123(3): 325-334, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31327465

RESUMO

BACKGROUND: Ketamine is a phencyclidine intravenous anaesthetic that blocks N-methyl-d-aspartate receptors and HCN channels in the CNS. Lately it has gained acceptance in a low-dose form, with studies showing an analgesic benefit in orthopaedic surgery. Our goal was to critically appraise and synthesise current evidence regarding use of low-dose ketamine in major, painful orthopaedic surgeries. METHODS: We conducted searches in Medline, Embase, Cochrane, and specialty journals for randomised controlled trials (RCTs) that compared low-dose ketamine to placebo. Primary outcomes included total opioid use, time to first opioid, and VAS pain scores. Meta-analyses were undertaken in RevMan software using a random effects model. We rated the quality of the evidence using the GRADE Working Group criteria. RESULTS: We included 20 studies across four subgroups for meta-analysis. The overall quality of the evidence was moderate. Ketamine significantly decreased total opioid use and pain scores (VAS) at 24 and 48 h (Opioid: standardised mean difference [SMD] -0.82 [-1.24, -0.40], p=0.0001, and -0.65 [-1.03,-0.27], p=0.0008; VAS: SMD -0.53 [-0.91, -0.15], p=0.006 and -0.60 [-1.05, -0.16], p=0.008), and delayed the time to first opioid dose (SMD 0.64 [0.01, 1.27], p=0.05). Results for nausea and hallucinations were equivocal, whereas results for chronic pain were inconclusive. The most prominent effects were seen in total joint operations. CONCLUSION: Low-dose ketamine is an effective adjuvant that decreases pain and opioid requirements in painful orthopaedic procedures, especially in the first 24 h after procedure. Future research should focus on arthroscopic procedures and the incidence of chronic pain.


Assuntos
Analgésicos/administração & dosagem , Ketamina/administração & dosagem , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Anestésicos Dissociativos/administração & dosagem , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Medição da Dor/métodos
8.
Gastroenterology ; 157(2): 320-348, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31320109

RESUMO

BACKGROUND & AIMS: We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS: We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS: The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS: Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.


Assuntos
Doença de Crohn/tratamento farmacológico , Medicina Baseada em Evidências/normas , Gastroenterologia/normas , Fármacos Gastrointestinais/uso terapêutico , Sociedades Médicas/normas , Canadá , Criança , Medicina Baseada em Evidências/métodos , Gastroenterologia/métodos , Humanos , Resultado do Tratamento
10.
Int J Evid Based Healthc ; 17 Suppl 1: S3-S5, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31283567

RESUMO

Currently in the Czech Republic, there does not exist such an institution as a 'National Centre for Clinical Practice Guidelines'. In 2017, there were about 123 professional medical organizations which developed about 1909 'guidelines' until 2017. However, the majority of these guidelines are 'expert opinion' or 'consensual' based 'guidance' or rather recommendations in the most cases missing a systematic approach that reflects evidence-based medicine principles and methods. The project is led by the Czech Health Research Council, the first partner is the Ministry of Health of the Czech Republic and the second partner is the Institute of Health Information and Statistics of the Czech Republic with support from policy makers, academics, clinicians and members of the Czech National Centre for Evidence-Based Healthcare and Knowledge Translations. This centre is an umbrella for three very important international collaborations which play a key role in Evidence-Based Healthcare, Evidence Synthesis, Evidence Implementation and trustworthy guidelines development. These are Cochrane Czech Republic, Masaryk University Grade Centre and the Czech Republic Centre for Evidence-Based Healthcare: The Joanna Briggs Institute Centre of Excellence.The main aim of this article is to present the Czech National Methodology of the Trustworthy Clinical Practice Guideline (CPG) development and the first results of the project 'Clinical Practice Guidelines'.A pilot phase of the project was realized during the first year of the project from January to December 2018. As the first step, there were established managing authorities including a Guarantee Committee and an Appraisal (Methodological) Committee. The Members of the Appraisal Committee developed a pilot version of the National Methodology of CPG development based on the best available approaches to Trustworthy CPGs development followed by testing on the first five pilot CPGs.


Assuntos
Medicina Baseada em Evidências/normas , Guias como Assunto/normas , República Tcheca , Medicina Baseada em Evidências/métodos , Humanos
11.
Int J Evid Based Healthc ; 17 Suppl 1: S6-S8, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31283568

RESUMO

The current article provides an overview of an approach to incorporating a range of evidence, including qualitative research findings, which the authors piloted when developing a clinical guideline on epilepsies in children and young people. We describe methods used for incorporating literature types not usually included in Scottish Intercollegiate Guidelines Network guidelines, including critical appraisal, and establishing dependability and credibility of qualitative findings. We highlight limitations encountered and make suggestions for future work.


Assuntos
Medicina Baseada em Evidências/normas , Guias como Assunto/normas , Adolescente , Criança , Pré-Escolar , Epilepsia/terapia , Medicina Baseada em Evidências/métodos , Humanos , Pesquisa Qualitativa , Escócia
12.
Int J Evid Based Healthc ; 17 Suppl 1: S12-S14, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31283570

RESUMO

BACKGROUND: According to the report published by the National Chamber of Physicians, currently the guideline development process in Poland is not coordinated and there is no document setting the standards for the process or methods of guideline production in Poland or institution assessing guideline quality on a regular basis. We postulated that adaptation of good-quality guidelines can improve the quality of the guidelines available and serve as a first step in translating evidence into practice by making physicians aware of the evidence. AIMS: To discuss methodological challenges and lessons learned during the project lead by the National Chamber of Physicians regarding guideline adaptation in Poland as a first step in evidence implementation. METHODS: The National Chamber of Physicians set up a project that involved adaptation of the guidelines with the use of a systematic approach suggested by the ADAPTE Collaboration. The guideline development team involved methodologist, clinical experts, specialists, primary care physician and patient representative. The process followed the framework established by the ADAPTE Toolkit. RESULTS/DISCUSSION: The topic in one the groups was management of depression in primary care. Key lesson learned during the process of defining clinical questions included the importance of cooperation between all involved groups due to differences in their point of views. Since several guideline documents were identified, one of the important lessons learned during the development of inclusion and exclusion criteria was to define a minimal set of methodological inclusion criteria because the documents found varied in the methods used and in the thoroughness of the description of the process. CONCLUSION: Well defined inclusion criteria, systematic use of available methods for the assessment of guideline quality and tools provided by the ADAPTE Toolkit refined to the needs of the guideline development groups facilitated the process of guideline adaptation in Poland as a first step in evidence implementation.


Assuntos
Medicina Baseada em Evidências/normas , Guias como Assunto/normas , Depressão/terapia , Humanos , Polônia , Atenção Primária à Saúde/métodos
13.
Int J Evid Based Healthc ; 17 Suppl 1: S18-S21, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31283572

RESUMO

BACKGROUND: Health services across the world are constantly introducing changes into their workplaces and these affect many people. As new robust and reliable evidence becomes available, it is important that changes to practice are made. As health professionals, we have to be flexible and accommodate this change; for some this means disruption, challenge and having to learn new ways of doing things. Barriers exist that prevent or delay changes being made to established practice in all organizations, whatever the culture. This is a world-wide problem. It is important to understand the barriers to change so that solutions can be found. Some changes that are needed don't occur, because clinicians are unaware of the new evidence, while for others there needs to be something introduced to drive forward the change. This process is not a passive one; active involvement is needed for the change to be successful. Individual attitudes and beliefs play a significant part in change, and their influences are often underestimated, so these also need to be explored. Practice change may require new skills to be learnt - another obstacle for change. AIM: In this short communication, the science behind evidence implementation is introduced and then some of the factors that impact on change are explored, drawing on three useful models and frameworks. CONCLUSION: Ultimately there remains a gap between interventions that research has shown to be effective and their translation into practice; this has to be closed.


Assuntos
Medicina Baseada em Evidências/normas , Pesquisa Médica Translacional/métodos , Difusão de Inovações , Humanos
16.
Am J Health Syst Pharm ; 76(8): 554-559, 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-31361866

RESUMO

PURPOSE: Implementation of the SAFE PAIN algorithm for reducing opioid use for chronic pain in older adults is described. SUMMARY: A multidisciplinary team at Sheppard Pratt Health System, the largest private provider of psychiatric care in Maryland, used lean methodology to identify the root causes for noncompliance to evidence-based practices for patients in the geropsychiatry unit treated for osteoarthritis or chronic back pain. The team collaborated to develop a facility-specific treatment algorithm, called SAFE PAIN (Sheppard Pratt Health System Algorithm For Elderly Patient Centered Analgesia Interdisciplinary Nagara), was based on the Center for Disease Control and Prevention's evidence-based recommendations that included nonpharmacologic interventions as a first-line therapy for patients with osteoarthritis or chronic back pain. Rates of prescribing new opioids and prescribing evidence-based alternative medications via the SAFE PAIN algorithm were evaluated from March 1 to September 30, 2017 and compared with baseline (2012-2016). The lean methodology interventions led to zero new opioid orders during the study period, a significant decrease compared with previous years (p < 0.01). The rates of prescribing evidence-based alternative medications increased significantly from the baseline period to postimplementation (p < 0.01). Lean methodology interventions also decreased waste in several processes. CONCLUSION: The prescribing rate of new opioids for osteoarthritis and chronic back pain decreased and the prescribing rate for evidence-based medications increased after implementation of the SAFE PAIN algorithm in a geropsychiatry unit.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Procedimentos Clínicos , Osteoartrite/tratamento farmacológico , Manejo da Dor/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/etiologia , Dor Crônica/reabilitação , Prescrições de Medicamentos/estatística & dados numéricos , Medicina Baseada em Evidências/organização & administração , Medicina Baseada em Evidências/normas , Feminino , Geriatria/organização & administração , Geriatria/normas , Fidelidade a Diretrizes , Implementação de Plano de Saúde , Humanos , Masculino , Maryland , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Osteoartrite/complicações , Osteoartrite/reabilitação , Manejo da Dor/normas , Equipe de Assistência ao Paciente/organização & administração , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Psiquiatria/organização & administração , Psiquiatria/normas
17.
J Vasc Surg ; 69(6S): 3S-125S.e40, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159978

RESUMO

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.


Assuntos
Cardiologia/normas , Medicina Baseada em Evidências/normas , Isquemia/terapia , Doença Arterial Periférica/terapia , Técnicas de Imagem Cardíaca/normas , Doença Crônica , Consenso , Testes de Função Cardíaca/normas , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Fatores de Risco , Terminologia como Assunto , Resultado do Tratamento
18.
J Clin Apher ; 34(3): 171-354, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31180581

RESUMO

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.


Assuntos
Remoção de Componentes Sanguíneos/métodos , Medicina Baseada em Evidências/normas , Humanos , Terapêutica/métodos , Estados Unidos , Redação
19.
PLoS Med ; 16(6): e1002819, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31185011

RESUMO

BACKGROUND: Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans. METHODS AND FINDINGS: Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review. CONCLUSIONS: To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published. PROTOCOL REGISTRATION: PROSPERO CRD42017067514.


Assuntos
Anti-Infecciosos/uso terapêutico , Resistência Microbiana a Medicamentos/efeitos dos fármacos , Medicina Baseada em Evidências/legislação & jurisprudência , Política de Saúde/legislação & jurisprudência , Antibacterianos/normas , Antibacterianos/uso terapêutico , Anti-Infecciosos/farmacologia , Anti-Infecciosos/normas , Resistência Microbiana a Medicamentos/fisiologia , Medicina Baseada em Evidências/normas , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos
20.
Crit Care ; 23(Suppl 1): 125, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200737

RESUMO

In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons.In this article, five dogmas relevant to critical care medicine are discussed and reviewed in the light of the available evidence. Dogma #1 relates to the treatment of oliguria with fluids, diuretics, and vasopressors. In this context, it should be considered that oliguria is a symptom rather than a disease. Thus, once hypovolaemia can be excluded as the underlying reason, there is no justification for giving fluids, which may do more harm than good in euvolaemic or hypervolaemic patients. Similarly, there is no solid evidence for forcing diuresis by administering vasopressors and loop diuretics. Dogma #2 addresses the treatment of crush syndrome patients with aggressive fluid therapy using NaCl 0.9%. In fact, this treatment may aggravate renal injury by iatrogenic metabolic acidosis and subsequent renal hypoperfusion. Dogma #3 concerns the administration of NaCl 0.9% to patients undergoing kidney transplantation. Since these patients are usually characterised by hyperkalaemia, the potassium-free solution NaCl 0.9%, containing exclusively 154 mmol/l of sodium and chloride ions each, is often considered as the fluid of choice. However, large volumes of chloride-rich solutions cause hyperchloraemic acidosis in a dose-dependent manner and induce a potassium shift to the extracellular space, thereby increasing serum potassium levels. Thus, balanced electrolyte solutions are to be preferred in this setting. Dogma #4 relates to the fact that enteral nutrition is often withheld for patients with high residual gastric volume due to the theoretical risk of gastro-oesophageal reflux, potentially resulting in aspiration pneumonitis. Despite controversial discussions, there is no clinical data supporting that residual gastric volume should be generally measured, especially not in patients without a gastro-intestinal surgery and/or motility disorders. Clinical evidence rather suggests that abandoning residual gastric volume monitoring does not increase the incidence of pneumonia, but may benefit patients by facilitating adequate enteral feeding. Finally, dogma #5 is about sedating all mechanically ventilated patients because "fighting" against the respirator may cause insufficient ventilation. This concern needs to be balanced against the unwanted consequences of sedation, such as prolonged mechanical ventilation and intensive care unit length of stay as well as increased risk of delirium. Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable.In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.


Assuntos
Cuidados Críticos/métodos , Medicina Baseada em Evidências/normas , Cuidados Críticos/tendências , Estado Terminal/terapia , Nutrição Enteral/métodos , Medicina Baseada em Evidências/tendências , Hidratação/métodos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/tendências , Respiração Artificial/métodos , Respiração Artificial/tendências , Urina/fisiologia
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