Auditing the implementation of SIGN (Scottish Intercollegiate Guidelines Network) clinical guidelines

Refractive Outcomes of Non-Toric and Toric Intraocular Lenses in Mild, Moderate and Advanced Keratoconus: A Systematic Review and Meta-Analysis

Background: To perform a systematic review and meta-analysis of the refractive outcomes of non-toric and toric intraocular lenses (IOLs) in keratoconus (KC) using different IOL power calculation formulas. Methods: A systematic search was conducted to identify studies that report on refractive outcomes of different IOL power calculation formulas in KC patients undergoing cataract surgery. Inclusion criteria were primary posterior chamber non-toric and toric monofocal intraocular lens implantation, data on the degree of KC, explicit mention of the formula used for each stage of KC, and the number of eyes in each category. We calculated and compared the absolute and mean prediction errors, percentage of eyes within 0.5 D and 1 D from target, and the weighted absolute prediction errors of IOL formulas, all were given for KC degrees I–III. Results: The bibliographic search yielded 582 studies published between 1996 and 2020, 14 of which (in total 456 eyes) met the criteria: three studies on non-toric IOL (98 eyes), eight studies on toric IOLs (98 eyes) and three studies of unknown separation between non-toric and toric IOLs (260 eyes). The lowest absolute prediction error (APE) for mild, moderate, and advanced KC was seen with Kane’s IOL power formula with keratoconus adjustment. The APE for the top five IOL power formulas ranged 0.49–0.73 diopters (D) for mild (83–94%) of eyes within 1 D from the target), 1.08–1.21 D for moderate (51–57% within 1 D), and 1.44–2.86 D for advanced KC (12–48% within 1 D). Conclusions: Cataract surgery in eyes with mild-to-moderate KC generally achieves satisfactory postoperative refractive results. In patients with advanced KC, a minority of the eyes achieved spherical equivalent refraction within 1 D from the target. The Kane’s formula with keratoconus adjustment showed the best results in all KC stages.

In Vivo Efficacy of Contact Lens Drug-Delivery Systems in Glaucoma Management. A Systematic Review

Adherence is crucial in medical glaucoma therapy, although half of the patients skip eyedrops. In recent years alternative drug-delivery systems have been developed. One of the most promising seems the contact lens (CL). This systematic review aims to present the in vivo efficacy of different CL drug-delivery systems. A total of 126 studies were identified following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 19 studies about CL drug-delivery systems were included. To date, the following drug-delivery systems have been investigated in vivo: drug-soaked CL, CL with physical barriers (vitamin E), molecularly imprinted CL, CL with implants, and nanoparticle-loaded CL. Nanoparticle-loaded CL and CL with implants seem the most promising drug-delivery systems, although initial burst drug release and patient acceptance may limit their widespread use in current practice. Clinical trials are warranted to understand the role of CL as a drug-delivery system in improving glaucomatous patient care.

Cannabinoids in Glaucoma Patients: The Never-Ending Story

Glaucoma is one of the principal causes of irreversible blindness worldwide. Yet, intraocular pressure (IOP) is the main modifiable risk factor for disease progression. In the never-ending challenge to develop new and effective drugs, several molecules have been tested as anti-glaucoma agents thanks to their pressure-lowering capabilities. Among these molecules, the cannabinoids have been investigated as possible anti-glaucoma drugs since the early 1970s. Cannabinoids are a large class of chemical compounds that exploit their effects by interaction with cannabinoid receptors 1 and 2. These receptors are widely expressed in the human retina where they may influence important functions such as photo-transduction, amacrine cell network maintenance, and IOP regulation. Therefore, in past years several studies have been conducted in order to assess the IOP lowering effects of cannabinoids. PRISMA guidelines have been used to perform a literature search on Pubmed and Scopus aiming to investigate the mechanism of IOP lowering effects and the potential benefits of orally administered, inhaled, topical, and intravenous cannabinoids in the treatment of glaucoma patients.

Bullous Central Serous Chorioretinopathy: A Rare and Atypical Form of Central Serous Chorioretinopathy. A Systematic Review

Bullous central serous chorioretinopathy (bCSCR) is a rare variant of the central serous chorioretinopathy, complicated by an exudative retinal detachment with shifting fluid. This systematic review aims to present the epidemiology, the pathogenesis, the clinical presentation, the imaging, the differential diagnosis, and the latest treatments of this disease. A total of 60 studies were identified following a literature search adhering to PRISMA guidelines. After full-text evaluation, 34 studies about bCSCR were included. bCSCR usually affects middle-aged men, and the principal risk factor is corticosteroid medications. Pathogenesis is related to an increased choroidal vessel and choriocapillaris permeability, with subsequent subretinal fluid accumulation, rich in fibrin, which may provoke the exudative retinal detachment. Clinical presentation and imaging are fundamental to distinguish bCSCR from other pathologies, avoiding unappropriated treatment. Corticosteroid withdraws (if assumed) and laser photocoagulation of leakage sites seen at angiography may speed up retinal reattachment. Verteporfin photodynamic therapy, transpupillary thermal therapy, oral eplerenone and scleral thinning surgery are other therapeutic options. An early diagnosis might prevent disease progression due to harmful medications as well as unnecessary surgery.

What Is the Impact of Intraoperative Microscope-Integrated OCT in Ophthalmic Surgery? Relevant Applications and Outcomes. A Systematic Review

Background: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. Method: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. Results: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. Conclusion: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.

Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation

Introduction

Timing of retinal detachment (RD) following cataract surgery is of importance for both diagnostic and prognostic factors. However, results on RD onset-time following cataract surgery have been conflicting.

Method

A systematic pooled analysis of the literature regarding timing of retinal detachment following cataract surgery. Outcomes were verified against an independent dataset.

Results

Twenty-one studies, reporting on rates of RD in 3,352,094 eyes of 2,458,561 patients, met our inclusion criteria and were included in the analysis. The mean pooled time to RD following surgery was 23.12 months (95% CI: 17.79-28.45 months) with high heterogeneity between studies (I ²=100%, P < 0.00001). Meta-analytic pooling for the risk of retinal detachment revealed a risk of 1.167% (95% CI: 0.900 to 1.468, I ²=99.50%, P < 0.0001). A retrospective chart review identified 54 pseudophakic RD cases (mean age 65.5, 59.3% males). The 95% confidence interval for the mean time to RD was 3.1-6.75 years.

Conclusions

The interval between cataract surgery and RD in a pooled analysis revealed a mean time of approximately 1.5-2.3 years. However, there was high variability between studies. Validation based on our local results showed similar yet slightly longer time frames. Timing of pseudophakic retinal detachment might direct appropriate follow-up, assisting in earlier detection.

Efficacy and safety of adalimumab in the treatment of non-infectious uveitis: a meta-analysis and systematic review

OBJECTIVE

To summarize updated evidences on the efficacy and safety of adalimumab (ADA) in the treatment of patients with non-infectious uveitis.

PATIENTS AND METHODS

A systematic search between January 2000 and September 2017 was conducted using PubMed, Embase, and Cochrane libraries. We investigated control of inflammation, improvement of visual acuity (VA), corticosteroid-sparing effect, and adverse events (AEs) or serious adverse events.

RESULTS

Three randomized clinical trials (RCTs) and 20 non-RCTs were included and analyzed. The pooled proportions of inflammation control were 74% (95% CI 64%-82%) and 79% (95% CI 69%-87%) in groups of ≤6- and ≥12-months follow-up durations. No significant difference was found between the two groups (χ2 = 0.920, p = 0.337). Analysis of subgroups classified by degree of being treatment-naïve for anti-TNFα agents showed the inflammation control reached a high of 87% (95% CI 80%-92%) when subjects were "almost naïve" to anti-TNFα before ADA treatment. VA was improved by three or more lines in 41.3% (52/126) eyes, and was equal to or better than the baseline in 88.8% (142/160) eyes. Corticosteroid sparing was observed in 82.0% (91/111) of the patients; among them, 48.8% (40/82) discontinued use of corticosteroid completely. Minor drug-related adverse events were reported. The treatment effects of ADA were generally consistent in the three RCTs, and ADA reduced the risk of treatment failure by 43%-75%.

CONCLUSION

The current review provided evidences that ADA might be a promising choice in reducing inflammatory activity, gaining VA, and sparing corticosteroid use with minor AEs when applied in treating non-infectious uveitis.

Meta-Analysis of the Relationship between CXCR4 Expression and Metastasis in Prostate Cancer

PURPOSE

Experimental studies have suggested that the stromal-derived factor-1 (SDF-1)/CXCR4 axis is associated with tumor aggressiveness and metastasis in several malignancies. We performed a meta-analysis to elucidate the relationship between CXCR4 expression and the clinicopathological features of prostate cancer.

MATERIALS AND METHODS

Data were collected from studies comparing Gleason score, T stage, and the presence of metastasis with CXCR4 levels in human prostate cancer samples. The studies were pooled, and the odds ratio (OR) of CXCR4 expression for clinical and pathological variables was calculated.

RESULTS

Five articles were eligible for the current meta-analysis. We found no relationship between CXCR4 expression and Gleason score (<7 vs. ≥7). The forest plot using the fixed-effects model indicated an OR of 1.585 (95% confidence interval [CI]: 0.793~3.171; p=0.193). Further, CXCR4 expression was not associated with the T stage (<T3 vs. ≥T3), and the relevant meta-analysis showed OR=1.803 (95% CI: 0.756~4.297, p=0.183). However, increased CXCR4 expression was strongly associated with metastatic disease with a fixed-effects pooled OR of 7.459 (95% CI: 2.665~20.878, p<0.001).

CONCLUSIONS

Our meta-analysis showed that the higher CXCR4 protein expression in prostate cancer specimens is significantly associated with the presence of metastatic disease. This supports previous experimental data supporting the role played by the SDF-1/CXCR4 axis in metastasis.

Impact of adherence to best practice guidelines on the diagnostic and assessment services for autism spectrum disorder

Despite their range and complexity, adherence to Scottish Intercollegiate Guidelines Network guideline for the diagnosis and assessment of autism spectrum disorders (ASD) was shown to be high within child development and specialist diagnostic clinics serving a geographical cohort of children diagnosed under the age of 7 years. A retrospective analysis of comprehensive clinical notes demonstrated that the recommended discretionary use of structured history instruments was increased after medical training (p = 0.003). 56% (51/90) of children received the diagnosis of ASD at their initial specialist appointment. 51% underwent the recommended discretionary structured observational instrument. This further assessment was more likely to be required for older children in the reaudited group (p = 0.001). The implications for service capacity planning when delivering best practice recommendations are discussed.

The diagnosis and treatment of bipolar disorder: recommendations from the current s3 guideline

BACKGROUND

Bipolar disorder is a serious mental illness, characterized by frequent recurrences and major comorbidities. Its consequences can include suicide.

METHODS

An S3 guideline for the treatment of bipolar disorder was developed on the basis of a systematic literature search, evaluation of the retrieved publications, and a formal consensus-finding procedure. Several thousand publications were screened, and 611 were included in the analysis, including 145 randomized controlled trials (RCT).

RESULTS

Bipolar disorder should be diagnosed as early as possible. The most extensive evidence is available for pharmacological monotherapy; there is little evidence for combination therapy, which is nonetheless commonly given. The appropriate treatment may include long-term maintenance treatment, if indicated. The treatment of mania should begin with one of the recommended mood stabilizers or antipsychotic drugs; the number needed to treat (NNT) is 3 to 13 for three weeks of treatment with lithium or atypical antipsychotic drugs. The treatment of bipolar depression should begin with quetiapine (NNT = 5 to 7 for eight weeks of treatment), unless the patient is already under mood-stabilizing treatment that can be optimized. Further options in the treatment of bipolar depression are the recommended mood stabilizers, atypical antipsychotic drugs, and antidepressants. For maintenance treatment, lithium should be used preferentially (NNT = 14 for 12 months of treatment and 3 for 24 months of treatment), although other mood stabilizers or atypical antipsychotic drugs can be given as well. Psychotherapy (in addition to any pharmacological treatment) is recommended with the main goals of long-term stabilization, prevention of new episodes, and management of suicidality. In view of the current mental health care situation in Germany and the findings of studies from other countries, it is clear that there is a need for prompt access to need-based, complex and multimodal care structures. Patients and their families need to be adequately informed and should participate in psychiatric decision-making.

CONCLUSION

Better patient care is needed to improve the course of the disease, resulting in better psychosocial function. There is a need for further high-quality clinical trials on topics relevant to routine clinical practice.

[S3 guidelines on diagnostics and therapy of bipolar disorders: development process and essential recommendations]

Bipolar disorders are severe psychiatric disorders with extensive individual and health economic consequences. Starting in 2007 the first German evidence and consensus based guideline for diagnostics and treatment of bipolar disorders was developed which holds the potential of increasing confidence of therapists, patients and relatives in the decision-making process and improving healthcare service experiences of patients and relatives. Apart from recommendations for diagnostics and treatment the guidelines provide those for trialogue action, knowledge transfer and self-help and for strategies for healthcare provision of this complex disorder. In the present article the methodology and essential recommendations are outlined and complemented in specific topics by corresponding articles in this special issue. Due to restrictions of the length of this presentation there is the need to refer to the comprehensive version of the guidelines at several points also regarding a detailed discussion of the limitations.

An audit of the implementation of guidelines in relation to the prevention of dental caries

AIM

To determine the implementation of national clinical guidelines in relation to the targeted prevention of dental caries in the permanent teeth of 6-16-year-olds presenting for dental care amongst training grade staff working within the Hospital Dental Service.

METHODS

Patient records were reviewed prospectively with regard to caries risk assessment, behaviour modification and tooth protection. Following dissemination of the results and reinforcement of fundamental points from the guideline, a second audit was conducted one month later. The results were assessed by chi2 (chi2) analysis.

RESULTS

One hundred patient records were reviewed in both Audit One (M:52; F:48) and Audit Two (M:61; F:39). Caries risk assessment was poorly recorded in both Audits One and Two (13% and 17%, respectively). There was an improvement in radiographic reporting between the first and second audit, from 53% to 80% (chi2 = 16.36, P = 0.001). Dietary advice and toothbrushing instruction were recorded in 36% and 41% of records in Audit One, whilst in Audit Two this had improved to 68% and 92%, respectively (chi2 = 20.51, P = 0.001 and chi2 = 58.38, P = 0.001). There was a statistically significant improvement in the prescription of fissure sealants in Audit Two (chi2 = 38.97, P = 0.001), although not in the prescription of topical fluoride application (chi2 = 1.71, P = 0.192).

CONCLUSION

Amongst training grade staff, there appears to be failure of implementation of certain aspects of SIGN guidelines for caries prevention. Clinical audit, however, would appear to improve guideline implementation.

Does obesity surgery improve psychosocial functioning? A systematic review

OBJECTIVE

The objective of this study is to present a review of the psychosocial outcome of bariatric surgery with special consideration of psychiatric comorbidity, psychopathology, psychosocial functioning, econometric data, and general quality of life (QoL).

PURPOSE

A review of all (non-) controlled trials of the last two decades both with a retrospective and prospective design and a follow-up period of at least 1 y.

RESEARCH METHODS AND PROCEDURES

The relevant literature was identified by a search of computerized databases. All articles published in English and German since 1980 were reviewed. Based on the requirements of the evidenced-based guidelines of the Agency for Health Care Policy and Research and the Scottish Intercollegiate Guidelines Network, each study was rated by a level of evidence.

RESULTS

In all, 171 publications were reviewed. Using the above inclusion/exclusion criteria, 63 articles including two systematic reviews were identified. A total of 40 studies focused on psychosocial outcome after obesity surgery.

CONCLUSION

Mental health and psychosocial status including social relations and employment opportunities improve for the majority of people after bariatric surgery thus leading to an improved QoL. Psychiatric comorbidity, predominantly affective disorders, and psychopathologic symptoms decrease postsurgically. A substantial percentage of bariatric surgery patients suffer from binge eating disorder or binge eating symptoms. The effect of bariatric surgery on the outcome of binge eating symptoms largely depends on the type of operation. With the exception of patients with a severe psychiatric comorbidity, the concern that obesity surgery will reinforce psychic symptoms and lead to a reduction in the QoL seems to be unfounded.