Evidence-based practice in traditional persian medicine (TPM): a stakeholder and social network analysis.

BACKGROUND: The utilization of complementary and alternative medicine (CAM) is experiencing a global surge, accompanied by the adoption of national CAM policies in numerous countries. Traditional Persian medicine (TPM) is highly used as CAM in Iran, and the ongoing scientific evaluation of its interventions and the implementation of evidence-based medicine (EBM) encounters various barriers. Therefore, comprehending the characteristics and interactions of stakeholders is pivotal in advancing EBM within TPM policies. In this study, we utilized both classical stakeholder analysis and social network analysis to identify key stakeholders and potential communication patterns, thereby promoting EBM in TPM policy-making. METHODS: A cross-sectional nationwide stakeholder analysis was conducted in 2023 using snowball sampling. The interviews were carried out using a customized version of the six building blocks of health. Data were collected through semi-structured interviews. Stakeholders were assessed based on five factors (power, interest, influence, position, and competency). The connections and structure of the network were analyzed using degree, betweenness, closeness centrality, and modularity index to detect clusters of smaller networks. RESULTS: Among twenty-three identified stakeholders, the Ministry of Health and Medical Education (MOHME) and the Public were the most powerful and influential. The Iranian Academy of Medical Sciences was the most competent stakeholder. Social network analysis revealed a low density of connections among stakeholders. Pharmaceutical companies were identified as key connectors in the network, while the Public, supreme governmental bodies, and guilds acted as gatekeepers or brokers. The MOHME and Maraji were found to be high-ranking stakeholders based on four different centrality measures. CONCLUSION: This study identifies powerful stakeholders in the network and emphasizes the need to engage uninterested yet significant stakeholders. Recommendations include improving competence through education, strengthening international relations, and fostering stronger relationships. Engaging key connectors and gatekeepers is essential for bridging gaps in the network.

[The S3 Guideline on the Treatment of Language Development Disorders: Summary of Recommendations]. / Die S3-Leitlinie zur Therapie von Sprachentwicklungsstörungen.

The S3 Guideline on the Treatment of Language Development Disorders: Summary of Recommendations Abstract: The German S3 Guidelines on the Treatment of Developmental Speech and Language Disorders (AWMF: No. 049-015) were published on the AWMF homepage at the end of 2022. The German Society for Phoniatrics and Paedaudiologie coordinated the work and developed the guideline text together with linguists and speech and language therapists. Many scientific medical societies consented to the respective recommendations. For the first time in the German-speaking area, the guideline group reviewed international research results on the treatment of various speech and language disorders and formulated evidence- or consensus-based recommendations for clinical care. The present article summarizes these recommendations and evaluates the guidelines from the perspective of child and adolescent psychiatry and psychotherapy.

Enhanced Recovery After Surgery in Laparoscopic Cholecystectomy - A Systematic Review.

BACKGROUND AND AIM: Enhanced Recovery After Surgery (ERAS) is a modern concept that aims to improve the perioperative patient care by implementing an evidence-based, patient-centered team approach. This paper aims to analyze the outcome, variations and limits of the ERAS-protocols used for laparoscopic cholecystectomy. Methods: We performed a systematic review on PubMed, Google Scholar, Web of Science to document the outcomes of applying various ERAS protocols in laparoscopic cholecystectomy (LC). After applying the inclusion and exclusion criteria, 8 papers, totaling 1453 patients that underwent LC, were included in the qualitative analysis. ERAS-protocols applied in those studies include various pre-, intra- and postoperative measures intended to boost the surgical recovery of the patients and shorten their hospital stay, without exposing them to hazardous encounters. Results: Patients undergoing laparoscopic cholecystectomy within an ERAS-specific protocol are proven to have lower levels of postoperative pain, nausea and vomiting, with no statistically significant risk of postoperative complications. The postoperative results show that ERAS-laparoscopic cholecystectomy is a feasible and safe procedure, that may shorten the postoperative recovery after LC. Conclusions: Further studies are needed to establish a consensus regarding the perioperative protocol, before implementing ERAS for LC in clinical routine.

Implementation of a High-Value, Evidence-Based Care Program: Impact and Opportunities for Learning Organizations.

GOAL: Value-based care is not simply a matter of cost, but also one of outcomes and harms per dollar spent. This definition encompasses three key components: healthcare delivery that is organized around patients' medical conditions, costs and outcomes that are actively and consistently measured, and information technology that enables the other two components. Our objective in this project was to implement and measure a systemwide high-value, evidence-based care initiative with five pillars of high-value practices. METHODS: We performed a quasi-experimental study from September 1, 2019, to August 31, 2022, of a new care program at the University of Texas Medical Branch. Drawing from the ABIM Foundation's Choosing Wisely Campaign, the program was based on five pillars-blood management and antimicrobial, laboratory, imaging, and opioid stewardship-with interdisciplinary teams led by institutional subject matter experts (i.e., administrative leaders) accompanied by nursing, information technology, pharmacy, and clinical and nonclinical personnel including faculty and trainees. Each pillar addressed two goals with targeted interventions to assess improvements during the first three fiscal years (FYs) of implementation. The targets were set at 10% improvement by the end of each FY. Monthly measurements were recorded for each FY. PRINCIPAL FINDINGS: We tracked performance toward 30 pillar goals and determined that the teams were successful in 50%, 50%, and 70% of their goals for FY 2020, 2021, and 2022, respectively. For example, in the antimicrobial stewardship FY 2021 pillar, one goal was to decrease meropenem days of therapy (DOT) by 10% (baseline was 45 DOT/1,000 patient days; the target was 40.5 DOT/1,000 patient days). We measured quarterly DOT/1,000 patient day rates of 32.02, 30.57, and 26.9, respectively, for a cumulative rate of 26.9. Critical interventions included engaging and empowering providers and service lines (including outliers whose performance was outside norms), educational conferences, and transparent data analyses. PRACTICAL APPLICATIONS: We showed that a multidisciplinary approach to the implementation of an evidence-based, high-value care program through a partnership of engaged administrative leaders, providers, and trainees can result in sustainable and measurable high-value healthcare delivery. Specifically, structuring the program with pillars to address defined metrics resulted in progressive improvement in meeting value-based goals at the University of Texas Medical Branch. Also, challenges can be embraced as learning opportunities to inform value-based interventions that range from technological to educational tactics. The results at the University of Texas Medical Branch provide a benchmark for the implementation of a program that engages, empowers, and aligns innovative value-based care initiatives.

[Need for improvement in the care of patients with Clostridioides difficile infections (CDI) - expert opinion in international comparison]. / Verbesserungsbedarf in der Versorgung von Patienten/-innen mit Clostridioides-difficile-lnfektionen (CDI) ­ Experten/-innenmeinung im internationalen Vergleich.

INTRODUCTION: Clostridioides difficile infection (CDI), as a nosocomial disease, is associated with high morbidity and mortality. Even though the incidence of CDI has been declining in Germany in recent years, the individual infection may pose a medical challenge despite therapeutic advances. The aim here is to clarify which gaps practitioners consider to be particularly serious in care and in the existing evidence base. METHODS: In a moderated workshop of German CDI experts the topics considered as relevant were identified. A survey already conducted in five other countries (Australia, France, Great Britain, Canada, and Italy) was adapted and processed by 27 practitioners. During the evaluation, the topics perceived as particularly important were identified, the statements of the specialist groups were compared and changes in opinion were considered. RESULTS: 27 fully completed questionnaires were evaluated. The need for improvement was primarily seen in the prevention of CDI recurrences (74.1%) and the treatment of recurrences (55.6%). Evidence deficits were noted in the treatment of recurrences (55.6%) and identification of risk factors for recurrences (48.1%). Improving care via fecal microbiota transfer (FMT) was named by 70.4%. For guidelines, more clarity (48.1%) and more regular updates (40.7%) were desired. For patients, better education on appropriate antibiotic use (52.0%) and choice of FMT were desired (48.1%). SUMMARY: The German expert view and the international assessment is similar, when asked about the need for improvement in care and evidence gaps in the treatment of patients with CDI: The focus is on prevention and therapy of recurrent CDI. The problem of access to FMT is a German peculiarity that seems to need improvement.

Machine learning to optimize literature screening in medical guideline development.

OBJECTIVES: In a time of exponential growth of new evidence supporting clinical decision-making, combined with a labor-intensive process of selecting this evidence, methods are needed to speed up current processes to keep medical guidelines up-to-date. This study evaluated the performance and feasibility of active learning to support the selection of relevant publications within medical guideline development and to study the role of noisy labels. DESIGN: We used a mixed-methods design. Two independent clinicians' manual process of literature selection was evaluated for 14 searches. This was followed by a series of simulations investigating the performance of random reading versus using screening prioritization based on active learning. We identified hard-to-find papers and checked the labels in a reflective dialogue. MAIN OUTCOME MEASURES: Inter-rater reliability was assessed using Cohen's Kappa (ĸ). To evaluate the performance of active learning, we used the Work Saved over Sampling at 95% recall (WSS@95) and percentage Relevant Records Found at reading only 10% of the total number of records (RRF@10). We used the average time to discovery (ATD) to detect records with potentially noisy labels. Finally, the accuracy of labeling was discussed in a reflective dialogue with guideline developers. RESULTS: Mean ĸ for manual title-abstract selection by clinicians was 0.50 and varied between - 0.01 and 0.87 based on 5.021 abstracts. WSS@95 ranged from 50.15% (SD = 17.7) based on selection by clinicians to 69.24% (SD = 11.5) based on the selection by research methodologist up to 75.76% (SD = 12.2) based on the final full-text inclusion. A similar pattern was seen for RRF@10, ranging from 48.31% (SD = 23.3) to 62.8% (SD = 21.20) and 65.58% (SD = 23.25). The performance of active learning deteriorates with higher noise. Compared with the final full-text selection, the selection made by clinicians or research methodologists deteriorated WSS@95 by 25.61% and 6.25%, respectively. CONCLUSION: While active machine learning tools can accelerate the process of literature screening within guideline development, they can only work as well as the input given by human raters. Noisy labels make noisy machine learning.

Lack of Clinical Evidence Regarding the Guidelines for Vitamin B12 Deficiency: An Analysis From Literature and Recommendations From Clinical Practice.

BACKGROUND: Vitamin B12 deficiency is a critical medical condition that, if left untreated, can lead to severe symptoms and potentially serious and life-threatening complications. Clinical guidelines are designed to provide a standardized approach to diagnosis and treatment, aiming for consistency and effectiveness. However, it is well-established that not all patients fit into general guidelines. OBJECTIVE: To investigate the clinical relevance of the submitted research to support these protocols for diagnosing and treating a B12 deficiency. APPROACH: Conducting a literature review of the references focused and used on diagnosing and treating vitamin B12 deficiency in adults and children. RESULTS: No robust clinical trial nor RCT has been found to back up the current protocols. The research used is primarily based on assumptions rather than solid clinical evidence. CONCLUSION: Existing guidelines for vitamin B12 deficiency need to be significantly revised and improved through clinical research, clinical experience by experts in the field with input from patient groups worldwide.

Plain language titleAnalyzing the Lack of Research on Vitamin B12 Deficiency Guidelines: Insights from Studies and Clinical AdvicePlain language summaryThis study dives into Vitamin B12 deficiency, stressing its serious health impacts and potential life-threatening complications when not treated. The study aims to investigate the scientific articles supporting these guidelines and their clinical relevance, conducting an in-depth analysis of literature references. The manuscript investigates and criticizes current guidelines for B12 deficiency, pointing out 4 key issues reported by patients and clinicians worldwide. The results are grouped into 4 sections: Maintenance Dose Protocol: The study questions the adequacy of maintenance doses every few months, highlighting a lack of clinical evidence and challenging the idea of sufficient liver stores. Oral Supplementation Protocol: The effectiveness of oral supplements is questioned due to inconclusive trials, focusing on raising blood values rather than assessing actual clinical outcomes. Diagnosing B12 Deficiency in Children: Guidelines neglect B12 deficiency in children despite significant differences in B12 levels between adults and healthy kids, potentially leading to underdiagnosis and unnecessary suffering. Delay in Diagnosis and Treatment: Factors like a lack of awareness and diverse symptoms contribute to delays, emphasizing the ongoing challenge of standardizing B12 assays. In the discussion, the manuscript argues that awareness of guidelines is low, and evidence-based guidelines may lack practical relevance. It suggests a significant revision of guidelines based on robust clinical evidence, advocating for personalized treatment, patient monitoring tools, controlled trials, and age-related healthy levels. Recognizing diverse patient needs and implementing individualized therapies are crucial for improving care for those with vitamin B12 deficiency, emphasizing the importance of early recognition and intervention.

Optimizing Quality of Life in Kidney Transplant Recipients Through Structured Exercise: A Systematic Review and Evidence-Based Guidelines.

With the progress of medicine and the maturity of surgery, the improvement of quality of life (QOL) in kidney transplant patients has gradually attracted widespread attention. There is evidence that exercise training has a beneficial effect on patients with renal transplantation. To discover whether exercise can improve patient QOL, this study collected the existing evidence about the effect of structured exercise training on the QOL of renal transplant recipients. Under the guidance of the 5 steps of evidence-based practice, relevant literature in various resources, from 2000 to 2023, was searched. Using the method of systematic review, a PRISMA table was made, and the studies were screened by inclusion and exclusion criteria. Then, the reports were reviewed and the data were extracted. Finally, 5 qualified randomized controlled trials for exercise training of renal transplant recipients were identified. All 5 studies evaluated the health outcomes of patients' QOL. Through the method of evidence-based practice, it was proven that exercise intervention can improve patient QOL after renal transplantation and accelerate their early postoperative recovery. This study integrates and discusses the evidence related to exercise training and QOL of renal transplant recipients to gain an in-depth understanding of the improvements of exercise on patients' QOL and the shortcomings of current clinical implementation. It provides evidence for medical staff to provide exercise interventions to help these transplant patients recover their health and return to daily life.

New horizons in clinical practice guidelines for use with older people.

Globally, more people are living into advanced old age, with age-associated frailty, disability and multimorbidity. Achieving equity for all ages necessitates adapting healthcare systems. Clinical practice guidelines (CPGs) have an important place in adapting evidence-based medicine and clinical care to reflect these changing needs. CPGs can facilitate better and more systematic care for older people. But they can also present a challenge to patient-centred care and shared decision-making when clinical and/or socioeconomic heterogeneity or personal priorities are not reflected in recommendations or in their application. Indeed, evidence is often lacking to enable this variability to be reflected in guidance. Evidence is more likely to be lacking about some sections of the population. Many older adults are at the intersection of many factors associated with exclusion from traditional clinical evidence sources with higher incidence of multimorbidity and disability compounded by poorer healthcare access and ultimately worse outcomes. We describe these challenges and illustrate how they can adversely affect CPG scope, the evidence available and its summation, the content of CPG recommendations and their patient-centred implementation. In all of this, we take older adults as our focus, but much of what we say will be applicable to other marginalised groups. Then, using the established process of formulating a CPG as a framework, we consider how these challenges can be mitigated, with particular attention to applicability and implementation. We consider why CPG recommendations on the same clinical areas may be inconsistent and describe approaches to ensuring that CPGs remain up to date.

Evidence-based clinical practice guidelines for the management of acute ankle injuries according to: a PRISMA systematic review and quality appraisal with AGREE II.

BACKGROUND: Acute ankle injuries are commonly seen in emergency rooms, with significant social impact and potentially devastating consequences. While several clinical practice guidelines (CPGs) related to ankle injuries have been developed by various organizations, there is a lack of critical appraisal of them. The purpose of this systematic review is to identify and critically appraise evidence-based clinical practice guidelines (EB-CPGs) related to acute ankle injuries in adults. METHOD: We conducted searches in the Cochrane Library, MEDLINE, EMBASE databases, WHO, and reviewed 98 worldwide orthopedic association websites up until early 2023. Two authors independently applied the inclusion and exclusion criteria, and each evidence-based clinical practice guideline (EB-CPG) underwent independent critical appraisal of its content by all four authors using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument. AGREE II scores for each domain were then calculated. RESULTS: This review included five evidence-based clinical practice guidelines. The mean scores for all six domains were as follows: Scope and Purpose (87.8%), Stakeholder Involvement (69.2%), Rigour of Development (72.5%), Clarity of Presentation (86.9%), Applicability (45.6%), and Editorial Independence (53.3%). CONCLUSION: The number of EB-CPGs related to ankle injuries are limited and the overall quality of the existing evidence-based clinical practice guidelines (EB-CPGs) for ankle injuries is not strong, with three of them being outdated. However, valuable guidance related to Ottawa rules, manual therapy, cryotherapy, functional supports, early ambulation, and rehabilitation has been highlighted. Challenges remain in areas such as monitoring and/or auditing criteria, consideration of the target population's views and preferences, and ensuring editorial independence. Future guidelines should prioritize improvements in these domains to enhance the quality and relevance of ankle injury management. SYSTEMATIC REVIEW: Systematic review.

Utilising systematic reviews to assess potential overtreatment and claim for better evidence-based research: an analysis of anticancer drugs versus supportive care in advanced esophageal cancer.

BACKGROUND: Highlighting the identified gaps in evidence-based research concerning advanced esophageal cancer (EC) treatment and care, this review evaluates the efficacy and safety of anticancer drugs compared to supportive care for advanced EC patients, aiming to assess the appropriateness of usual treatments and identify the gaps that need to be filled with primary research. METHODS: We searched (May 2022) MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries (ClinicalTrials.gov and PROSPERO) for randomised controlled trials (RCTs) comparing anticancer drugs (chemotherapy, immunotherapy, or biological/targeted therapy) with supportive care in advanced EC. The results were summarised using GRADE summary of finding tables. RESULTS: We included 15 RCTs. Most studies did not have a special focus on EC, did not detail the treatment lines in all patients, and did not evaluate all outcomes. Anticancer drugs may result in a slight increase in overall survival (OS) (HR 0.78; 95% CI 0.71, 0.86; MD 0.83 months) and better progression-free survival (PFS) (HR 0.56 95% CI 0.49, 0.64, MD 0.68 months), but also may increase toxicity (RR 1.37; 95% CI 1.13, 1.65), without a significant improvement in quality of life. The certainty of evidence was low or very low due to indirectness of results and lack of specific focus on EC in some studies. CONCLUSION: RCTs on advanced EC lack specificity, detailed treatment line information, and evaluation of all relevant outcomes. Moreover, when they find any benefit, this is negligible. Therefore, the certainty to justify anticancer drug treatments instead of supportive care in advanced EC is low or very low, and this information should be actively shared with affected patients. More and better RCTs should be conducted to assess whether any old or new proposed treatment for advanced EC patients provides a better balance of benefits and harms than the supportive care. SYSTEMATIC REVIEW REGISTRATION: The study protocol was registered in OSF ( https://doi.org/10.17605/OSF.IO/7CHX6 ) on 2022-03-29.