Search

ADHD is the most common neurodevelopmental disorder presenting to child and adolescent mental health, paediatric, and primary care services. Timely and effective interventions to address core ADHD symptoms and co-occurring problems are a high priority for healthcare and society more widely. While much research has reported on the benefits and adverse effects of different interventions for ADHD, these individual research reports and the reviews, meta-analyses and guidelines summarizing their findings are sometimes inconsistent and difficult to interpret. We have summarized the current evidence and identified several methodological issues and gaps in the current evidence that we believe are important for clinicians to consider when evaluating the evidence and making treatment decisions. These include understanding potential impact of bias such as inadequate blinding and selection bias on study outcomes; the relative lack of high-quality data comparing different treatments and assessing long-term effectiveness, adverse effects and safety for both pharmacological and non-pharmacological treatments; and the problems associated with observational studies, including those based on large national registries and comparing treatments with each other. We highlight key similarities across current international clinical guidelines and discuss the reasons for divergence where these occur. We discuss the integration of these different perspective into a framework for person/family-centered evidence-based practice approach to care that aims to achieve optimal outcomes that prioritize individual strengths and impairments, as well as the personal treatment targets of children and their families. Finally, we consider how access to care for this common and impairing disorder can be improved in different healthcare systems., European Child & Adolescent Psychiatry, 32 (8), ISSN:1435-165X, ISSN:1018-8827

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine. ispartof: ANAESTHESIA vol:76 issue:8 pages:1082-1097 ispartof: location:England status: published

Background Functional dyspepsia (FD) is one of the most common conditions in clinical practice. In spite of its prevalence, FD is associated with major uncertainties in terms of its definition, underlying pathophysiology, diagnosis, treatment, and prognosis. Methods A Delphi consensus was initiated with 41 experts from 22 European countries who conducted a literature summary and voting process on 87 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 36 statements. Results The panel agreed with the definition in terms of its cardinal symptoms (early satiation, postprandial fullness, epigastric pain, and epigastric burning), its subdivision into epigastric pain syndrome and postprandial distress syndrome, and the presence of accessory symptoms (upper abdominal bloating, nausea, belching), and overlapping conditions. Also, well accepted are the female predominance of FD, its impact on quality of life and health costs, and acute gastrointestinal infections, and anxiety as risk factors. In terms of pathophysiological mechanisms, the consensus supports a role for impaired gastric accommodation, delayed gastric emptying, hypersensitivity to gastric distention, Helicobacter pylori infection, and altered central processing of signals from the gastroduodenal region. There is consensus that endoscopy is mandatory for establishing a firm diagnosis of FD, but that in primary care, patients without alarm symptoms or risk factors can be managed without endoscopy. There is consensus that H. pylori status should be determined in every patient with dyspeptic symptoms and H. pylori positive patients should receive eradication therapy. Also, proton pump inhibitor therapy is considered an effective therapy for FD, but no other treatment approach reached a consensus. The long‐term prognosis and life expectancy are favorable. Conclusions and Inferences A multinational group of European experts summarized the current state of consensus on the definition, diagnosis and management of FD., Key summary Current knowledge Functional dyspepsia is one of the most common conditions encountered in clinical practice.There is a lack of guidance for clinicians in guiding diagnosis and treatment of this prevalent condition.No treatments are currently approved for the treatment of functional dyspepsia in Europe. What is new here A Delphi panel consisting of 41 experts from 22 European countries established the level of consensus on 87 statements regarding functional dyspepsia.The statements reaching consensus serve to guide clinicians in recognizing, diagnosing and treating FD in clinical practice.Endoscopy is mandatory for establishing a firm diagnosis of functional dyspepsia D, but in primary care patients without alarm symptoms or risk factors can be managed without endoscopy. Helicobacter pylori status should be determined in every patient with dyspeptic symptoms and H. Pylori positive patients should receive eradication therapy.Proton pump inhibitor‐therapy is considered an effective therapy for FD, but no other treatment approach reached consensus support.

Evidence-based medicine plays a leading role in modern clinical practice. The most well-known scales for evaluating the quality of evidence and recommendations based on them are OCEBM (Oxford Centre for Evidence-based Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation), NICE (National Institute for Health and Care excellence). Objective: to acquaint readers with modern clinical guidelines for conservative treatment of osteoarthritis (OA), developed on the basis of the principles of evidence-based medicine. GRADE scale is widely used. The greatest authority among professionals have community leaders: ACR (American College of Rheumatologists), EULAR (European Antirheumatic League), OARSI (International Society of Osteoarthritis Researchers), AAOS (American Academy of Orthopedic Surgeons), ESCEO (European Society for Clinical and Economic Studies aspects of osteoporosis, osteoarthritis and musculoskeletal diseases). Their differences are due, in particular, to the use of different scales for assessing the levels of evidence and strength recommendations and relating to the use of SYSADOA (symptomatic slow-acting drugs for the treatment of OA), intra-articular injections of various drugs (corticosteroids, PRP, hyaluronic acid, etc.). The article presents strictly and conditionally recommended methods of conservative treatment of osteoarthritis of the hand, knee and hip joints. Conclusions: modern clinical guidelines are based on objective scales for evaluating evidence and recommendations, respectively, the probability of systematic errors is reduced. Therefore, prescribing according to them OA treatment regimes, we are sure that we choose the most effective among all available approaches., Доказательная медицина играет ведущую роль в современной клинической практике. Самыми известными шкалами оценивания качества доказательств и рекомендаций на их основе являются: ОCEBM (Oxford Centre for Evidence-based Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation), NICE (National Institute for Health and Care excellence).Цель: познакомить читателей с современными клиническими рекомендациями по консервативному лечению остеоартроза (ОА), разработанными на основе принципов доказательной медицины. Для их создания чаще всего используют шкалу GRADE. Среди рекомендаций наибольший авторитет имеют сообщества: ACR (Американский колледж ревматологов), EULAR (Европейская антиревматическая лига), OARSI (Международное общество исследователей остеоартрита), AAOS (Американская академия хирургов-ортопедов), ESCEO (Европейское общество по клиническим и экономическим аспектам остеопороза, остеоартрита и костно-мышечных заболеваний). Различия между рекомендациями связаны, в частности, с использованием различных шкал оценивания уровней доказательности и силы рекомендаций и касаются применения SYSADOA (симптоматических медленнодействующих препаратов для лечения ОА), внутрисуставных инъекций различных средств (кортикостероидов, PRP, гиалуроновой кислоты и т. п.) и т. д. В статье приводятся строго и условно рекомендуемые методы консервативного лечения остеоартроза кисти, коленного и тазобедренного суставов.Выводы: современные клинические рекомендации создаются на основе объективных шкал оценки доказательств и рекомендаций, соответственно, вероятность систематических ошибок снижена. Поэтому, назначая согласно им пациенту с ОА методики лечения, мы уверены, что выбираем наиболее эффективные из всех имеющихся подходов., Доказова медицина відіграє провідну роль у сучасній клінічній практиці. Найвідомішими шкалами оцінювання якості доказів і рекомендацій на їхній основі є ОCEBM (Oxford Centre for Evidence-based Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation), NICE (National Institute for Health and Care excellence).Мета: ознайомити читачів із сучасними клінічними рекомендаціями щодо консервативного лікування остеоартрозу (ОА), розробленими на підставі принципів доказової медицини. Для їхнього створення найчастіше використовують шкалу GRADE. Серед рекомендацій найбільший авторитет мають спільноти: ACR (Американський коледж ревматологів), EULAR (Європейська антиревматична ліга), OARSI (Міжнародне товариство дослідників остеоартриту), AAOS (Американська академія хірургів-ортопедів), ESCEO (Європейське товариство з клінічних і економічних аспектів остеопорозу, остеоартриту і кістково-м’язових захворювань). Відмінності між рекомендаціями пов’язані, зокрема, із використанням різних шкал оцінювання рівнів доказовості та сили рекомендацій і стосуються застосування SYSADOA (симптоматичних повільнодіючих препаратів для лікування ОА), внутрішньосуглобових ін’єкцій різних засобів (кортикостероїдів, PRP, гіалуронової кислоти тощо) і т. п. У статті наводяться строго та умовно рекомендовані методи консервативного лікування остеоартрозу кисті, колінного та кульшового суглобів.Висновки: сучасні клінічні рекомендації створюються на основі об’єктивних шкал оцінювання доказів і рекомендацій, відповідно, ймовірність систематичних помилок знижена. Тому, призначаючи згідно з ними пацієнту з ОА методики лікування, ми впевнені, що вибираємо найбільш ефективні серед усіх наявних підходів.

Aim of this systematic review was to assess the efficacy of preventive interventions against the development of white spot lesions (WSLs) during fixed appliance orthodontic treatment. Nine databases were searched without limitations in September 2018 for randomized trials. Study selection, data extraction and risk of bias assessment were done independently in duplicate. Random-effects meta-analyses of mean differences (MDs) or relative risks (RRs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity analyses, and the GRADE analysis of the evidence quality. A total of 24 papers (23 trials) were included, assessing preventive measures applied either around orthodontic brackets (21 trials; 1427 patients; mean age 14.4 years) or molar bands (2 trials; 46 patients; age/sex not reported). Active patient reminders were associated with reduced WSL incidence on patient level compared to no reminder (3 trials; 190 patients; RR: 0.4; 95% CI: 0.31-0.64; Number Needed to Treat [NNT]: 3 patients), flat surface sealants were associated with reduced WSL incidence on tooth level than no sealant (5 trials; 2784 teeth; RR: 0.8; 95% CI: 0.63-0.95; NNT: 33 teeth), and fluoride varnish was associated with reduced WSL severity on tooth level (2 trials; 1160 teeth; MD: -0.32 points; 95% CI: -0.44 to -0.21 points). However, the quality of evidence was low according to GRADE, due to risk of bias. Some evidence indicates that active patient reminders and flat surface sealants or fluoride varnish around orthodontic brackets might be associated with reduced WSL burden, but further research is needed. Keywords: adverse effects; clinical trials; dental caries; evidence-based medicine; fixed appliances; systematic review.

Background and aims. Cerebral bypasses are categorized according to function (flow augmentation or flow preservation) and to characteristics: direct, indirect or combined bypass, extra-to-intracranial or intra-to-intracranial bypass, and high-, moderate- or low-capacity bypass. We critically summarize the current state of evidence and grades of recommendation for cerebral bypass surgery.

Background Pediatric primary care is the cornerstone of health care services for children. Performance of common office procedures is an integral part of primary care. Ideally, the community-based primary care pediatrician provides comprehensive health care services and only refers a small minority of patients for consultation. However, knowledge regarding Israeli pediatricians’ practices of office procedures is scant. Objectives To describe primary care pediatricians’ patterns in the provision of common office procedures and to analyze factors associated with performance or referral. Methods Design: Self-completed structured questionnaire consisting of 1) demographic variables; 2) practice characteristics description; 3) List of ten procedures (treatment of subungual hematoma, laceration suturing and adhesive closure, elbow subluxation/reduction , urinary bladder catheterization, supra-pubic aspiration, inguinal hernia reduction, umbilical granuloma and labial fusion treatment, and short lingual frenulum management) followed by questions regarding referral practice for each procedure; and 4) causes and indications for referral when relevant. Participants: Primary care pediatricians attending anational pediatric conferences. Analysis: Descriptive statistics and association assessment. Results The questionnaire was completed by 162 primary care pediatricians, 58.7 % male; mean age 53 ± 9 years, 88.4 % board certified. Of the respondents, 57 % worked in group practices and the remainder solo; salaried employees 68.2 %, independent contractors 31.8 %. Referral rate varied by procedure; least likely to be referred was labial fusion (7.7 %) and most likely was short lingual frenulum (81.3 %). For most procedures, the most frequent non-performance cause was lack of expertise followed by lack of appropriate conditions. The overall number of procedures in which the response selected was out-of-clinic referral was not associated with demographic or employment characteristics. However, association was found for certain specific procedures (e.g. experience with catheterization, gender with suturing and adhesive closure). Conclusions Many common office procedures are referred out of primary care pediatric community settings in Israel. Considerable variability was found among procedures. Lack of experience or lack of appropriate conditions were frequently reported causes for referral and need to be addressed in reducing unnecessary referral with its attendant costs and patient inconvenience. Possible approaches include updates in pediatric residency training, focused in-service training, time allocation and work environment reorganization.