The quality of diagnostic guidelines for children in primary care: A meta-epidemiological study

AIM

To determine the quality of paediatric guidelines relevant to diagnosis of three of the most common conditions in primary care: fever, gastroenteritis and constipation.

METHODS

We undertook a meta-epidemiological study of paediatric guidelines for fever, gastroenteritis and gastroenteritis. We systematically searched MEDLINE, Embase, Trip Database, Guidelines International Network, the National Guideline Clearinghouse and WHO from February 2011 to September 2022 for guidelines from high-income settings containing diagnostic recommendations. We assessed the quality of guideline reporting for included guidelines using the AGREE II tool.

RESULTS

We included 16 guidelines: fever (n = 7); constipation (n = 4) and gastroenteritis (n = 5). The overall quality across the three conditions was graded moderate (median AGREE II score 4.5/7, range 2.5-6.5) with constipation guidelines rated the highest (median 6/7), and fever rated the lowest (median 3.8/7). Major methodological weaknesses included consideration of guideline applicability. Half of the guidelines did not report involving parent representatives, and 56% did not adequately declare or address their competing interests.

CONCLUSIONS

Substantial variations exist in the quality of paediatric guidelines related to the diagnosis of primary care presentations. Better quality guidance is needed for general practitioners to improve diagnosis for children in primary care.

The quality of paediatric asthma guidelines: evidence underpinning diagnostic test recommendations from a meta-epidemiological study

BACKGROUND

Asthma is one of the most frequent reasons children visit a general practitioner (GP). The diagnosis of childhood asthma is challenging, and a variety of diagnostic tests for asthma exist. GPs may refer to clinical practice guidelines when deciding which tests, if any, are appropriate, but the quality of these guidelines is unknown.

OBJECTIVES

To determine (i) the methodological quality and reporting of paediatric guidelines for the diagnosis of childhood asthma in primary care, and (ii) the strength of evidence supporting diagnostic test recommendations.

DESIGN

Meta-epidemiological study of English-language guidelines from the United Kingdom and other high-income countries with comparable primary care systems including diagnostic testing recommendations for childhood asthma in primary care. The AGREE-II tool was used to assess the quality and reporting of the guidelines. The quality of the evidence was assessed using GRADE.

RESULTS

Eleven guidelines met the eligibility criteria. The methodology and reporting quality varied across the AGREE II domains (median score 4.5 out of 7, range 2-6). The quality of evidence supporting diagnostic recommendations was generally of very low quality. All guidelines recommended the use of spirometry and reversibility testing for children aged ≥5 years, however, the recommended spirometry thresholds for diagnosis differed across guidelines. There were disagreements in testing recommendations for 3 of the 7 included tests.

CONCLUSIONS

The variable quality of guidelines, lack of good quality evidence, and inconsistent recommendations for diagnostic tests may contribute to poor clinician adherence to guidelines and variation in testing for diagnosing childhood asthma.

Alignment of Doctors' Understanding of Treatment Burden Priorities and Chronic Heart Failure Patients' Experiences: A Nominal Group Technique Consultation

PURPOSE

To identify and rank areas of treatment burden in chronic heart failure (CHF), including solutions, that should be discussed during the clinical encounter from a patient, and doctors' perspective.

PATIENTS AND METHODS

Patients with CHF and clinicians managing heart failure were invited. Nominal group technique sessions held either face to face or online in 2021-2022, with individual identification of priorities and voting on ranking.

RESULTS

Four patient groups (N=22) and one doctor group (N=5) were held. For patients with heart failure, in descending order of priority Doctor-patient communication, Inefficiencies of the healthcare system, Healthcare access issues, Cost implications of treatment, Psychosocial impacts on patients and their families, and Impact of treatment work were the most important treatment burdens. Priorities independently identified by the doctors aligned with the patients' but ranking differed. Patient solutions ranged from involvement of nurses or pharmacists to enhance understanding of discharge planning, through to linkage between health information systems, and maintaining strong family or social support networks. Doctors' solutions covered timing medicines with activities of daily living, patient education on the importance of compliance, medication reviews to overcome clinical inertia, and routine clinical audits.

CONCLUSION

The top treatment burden priorities for CHF patients were related to interaction with clinicians and health system inefficiencies, whereas doctors were generally aware of patients' treatment burden but tended to focus on the complexity of the direct treatment work. Addressing the priority issues identified here can commence with clinicians becoming aware of the issues that matter to patients and proactively discussing feasible immediate and longer-term solutions during clinical encounters.

Patient and physician perspectives on treatment burden in end-stage kidney disease: a nominal group technique study

OBJECTIVES

The treatment workload associated with end-stage kidney disease (ESKD) is high. The treatment burdens experienced by patients with ESKD are not well understood. In this study, we aimed to elucidate the most important areas of treatment burden for discussion in a clinical encounter from the perspectives of patients with ESKD and nephrologists. We sought to explore possible solutions to these high priority treatment burden challenges.

DESIGN

Nominal group technique (NGT) sessions.

SETTING AND PARTICIPANTS

Three in-person NGT sessions were conducted with 19 patients with dialysis-dependent ESKD from one tertiary treatment centre (mean age 64 years; range 47-82). All patients were either retired or on a disability pension; 74% perceived moderate or severe treatment burden; and 90% spent more than 11 hours on treatment-related activities per week (range 11-30). One online NGT session was conducted with six nephrologists from two Australian states.

MAIN OUTCOME MEASURES

The primary outcome was a ranked list of treatment burden priorities. The secondary outcome was potential solutions to these treatment burden challenges.

RESULTS

Every patient group ranked health system issues as the most important treatment burden priority. This encompassed lack of continuity and coordination of care, dissatisfaction with frequent healthcare encounters and challenges around healthcare access. Psychosocial burdens on patients and families were perceived to be the most important area of treatment burden by physicians, and were ranked the second highest priority by patients.

CONCLUSIONS

Discussing treatment burden in a clinical encounter may lead to a better understanding of patients' capacity to cope with their treatment workload. This could facilitate tailored care, improve health outcomes, treatment sustainability and patients' overall quality of life.

Treatment Burden Discussion in Clinical Encounters: Priorities of COPD Patients, Carers and Physicians

Purpose

Many people with chronic obstructive pulmonary disease (COPD) feel overburdened with the treatment and management of their illness. Although research has begun to shed light on how COPD patients experience treatment burden, most of what we know is limited to personal experiences of patients. The aim of this study is to identify and prioritise areas of treatment burden that should be discussed during the clinical encounter from the perspectives of COPD patients, carers, and respiratory physicians.

Patients and Methods

Data were collected from participants using the nominal group technique. Five nominal group sessions were conducted in total (n = 31); three sessions with patients (n = 18), one with carers (n = 7) and another with respiratory physicians (pulmonologists or chest physicians) (n = 6). Each session was recorded and analyzed using thematic analysis.

Results

Going beyond understanding patients’ and carers’ experiences of treatment burden, this study offers a practical viewpoint of what should be discussed in a clinical encounter. Each group of participants contextualized treatment burden issues for discussion from their own perspectives. There was strong agreement, however, across the groups that difficulties accessing healthcare, lack of education and information, and worry about COPD treatment and prognosis were the most important treatment burden priorities for discussion.

Conclusion

Understanding and creating opportunities to discuss these issues in a clinical encounter is important in not only reducing treatment burden but also improving health outcomes and quality of life for COPD patients and their carers.

Brain Volume Fractions in Mammals in Relation to Behavior in Carnivores, Primates, Ungulates, and Rodents

The volume fraction (VF) of a given brain region, or the proper mass, ought to reflect the importance of that region in the life of a given species. This study sought to examine the VF of various brain regions across 61 different species of mammals to discern if there were regularities or differences among mammalian orders. We examined the brains of carnivores (n = 17), ungulates (n = 8), rodents (n = 7), primates (n = 11), and other mammals (n = 18) from the online collections at the National Museum of Health and Medicine. We measured and obtained the VF of several brain regions: the striatum, thalamus, neocortex, cerebellum, hippocampus, and piriform area. We refined our analyses by using phylogenetic size correction, yielding the corrected (c)VF. Our groups showed marked differences in gross brain architecture. Primates and carnivores were divergent in some measures, particularly the cVF of the striatum, even though their overall brain size range was roughly the same. Rodents predictably had relatively large cVFs of subcortical structures due to the fact that their neocortical cVF was smaller, particularly when compared to primates. Not so predictably, rodents had the largest cerebellar cVF, and there were marked discrepancies in cerebellar data across groups. Ungulates had a larger piriform area than primates, perhaps due to their olfactory processing abilities. We provide interpretations of our results in the light of the comparative behavioral and neuroanatomical literature.

Working in global health: A planning and implementation framework for international electives

Purpose: Propose a framework for planning and undertaking an international elective. Methods: On returning from conducting maternal health and well-being research in several remote communities in India, two undergraduate medical students have reflected on and documented their experiences with the view to assisting other students (and their supervisors) considering undertaking an international elective. Results: A framework for undertaking clinical or research electives in remote or rural communities is presented. The framework comprises three distinct phases: Pre-departure planning and briefing, in-country experiences and returning from the elective and considers a range of factors to ensure that, as a minimum, visiting students "do no harm" and are themselves not harmed. Conclusions: Students' home institutions have a duty of care for preparing them for their international electives by providing pre-departure training, support during the elective and comprehensive de-briefing on their return. These electives should be evaluated (including by host communities) to ensure that exchanges are socially accountable, with no harm to the often-vulnerable communities in which students gain considerable experience. Also important is that future students build on the positive experiences of their predecessors to ensure sustainability of any interventions in host communities.

Cross-sectional analysis of the reporting of continuous outcome measures and clinical significance of results in randomized trials of non-pharmacological interventions

Background

Reporting the scoring details of continuous outcome measures in randomized trials allows readers to interpret the size of any effect of the intervention. This study aimed to determine, in a sample of randomized trials: 1) the completeness of reporting of scoring details for continuous outcome measures, and 2) whether trial authors comment on the clinical significance of statistically significant trial results.

Methods

A descriptive analysis of randomized trials of non-pharmacological interventions published during 2009 in the six leading general medical journals (n = 138), and which used at least one continuous outcome measure (n = 85). From each trial report, two authors independently extracted the following information about each continuous outcome measure: the reporting of its scoring details, presentation of its results, and the reporting and justification of the clinical significance of the results.

Results

Across the 84 trials, we identified 336 continuous outcome measures. A total of 146 (44%) were published measures, 12 (4%) were adapted from published measures, 5 (1%) were developed for the trial, and 173 (51%) were ‘conventional measures’ for which scoring details are not necessary (such as weight). For 57 (35%) of the 163 non-conventional outcome measures no scoring details or reference to the outcome measure were provided in the trial report. Of the 159 outcome measures with a statistically significant result, clinical significance was not mentioned for 81 (51%) and was reported without any elaboration or justification for 39 (25%) of them.

Conclusions

Scoring details of continuous outcome measures used in this sample of randomized trials of non-pharmacological interventions were incompletely reported, which hampers interpretation of a trial’s results. Complete reporting of scoring details is important when considering the clinical significance of the results. When deciding about an intervention, having this information may help clinicians in their conversations with patients about the possible benefits and harms, and their size, of the intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-362) contains supplementary material, which is available to authorized users.

Hydration of the peptide backbone largely defines the thermodynamic propensity scale of residues at the C' position of the C-capping box of alpha-helices

The C' position of the C-capping box is the second residue outside of the helix. Statistical analysis of residue distribution at the C' position in the alpha-helices' C-capping box showed that different amino acid residues occur with different probabilities, with the strongest preference being for glycine. To understand the physico-chemical basis for this preference, we studied the effects that 17 amino acid substitutions at the C' position in an alpha-helix of ubiquitin have on the stability of this protein. We determined the following rank order of amino acid residues at the C' position with respect to their effect on the stability: Gly>His>Asn>Arg>Lys>Gln>Ala>Phe>Met>Ser>Asp>Glu>Trp>Thr>Pro>Ile>Val. The effect of the amino acid substitutions on the structure also was evaluated by comparing the (1)H-(15)N heteronuclear sequential quantum correlation spectra and showed no significant changes in the structures of the most stable (Gly) and the least stable (Val) variants. The obtained changes in stability highly correlate (r = 0.85) with the statistical distribution of the residues at the C' position indicating that the measured thermodynamic propensities are unbiased by secondary interactions. We also found that the measured thermodynamic propensities correlate well with the amide hydrogen exchange data on short model peptides (r = 0.85) and the calculated hydration of the peptide backbone (r = 0.88). These results combined with the changes in enthalpy and entropy of unfolding of ubiquitin variants suggest that dehydration of the peptide backbone plays a significant role in defining the thermodynamic propensity scale at the C' position of the C-capping box in alpha-helices. This propensity scale is useful for protein secondary structure predictions and protein design.

Contribution of the 30/36 hydrophobic contact at the C-terminus of the alpha-helix to the stability of the ubiquitin molecule

The contribution of the hydrophobic contact in the C-capping motif of the alpha-helix to the thermodynamic stability of the ubiquitin molecule has been analyzed. For this, 16 variants of ubiquitin containing the full combinatorial set of four nonpolar residues Val, Ile, Leu, and Phe at C4 (Ile30) and C' ' (Ile36) positions were generated. The secondary structure content as estimated using far-UV circular dichroism (CD) spectroscopy of all but Phe variants at position 30 did not show notable changes upon substitutions. The thermodynamic stability of these ubiquitin variants was measured using differential scanning calorimetry, and it was shown that all variants have lower stability as measured by decreases in the Gibbs energy. Since in some cases the decrease in stability was so dramatic that it rendered an unfolded protein, it was therefore concluded that, despite apparent preservation of the secondary structure, the 30/36 hydrophobic contact is essential for the stability of the ubiquitin molecule. The decrease in the Gibbs energy in many cases was found to be accompanied by a large (up to 25%) decrease in the enthalpy of unfolding, particularly significant in the variants containing Ile to Leu substitutions. This decrease in enthalpy of unfolding is proposed to be primarily the result of the perturbed packing interactions in the native state of the Ile --> Leu variants. The analysis of these data and comparison with effects of similar amino acid substitutions on the stability of other model systems suggest that Ile --> Leu substitutions cannot be isoenergetic at the buried site.

Heat capacity change for ribonuclease A folding

The change in heat capacity deltaCp for the folding of ribonuclease A was determined using differential scanning calorimetry and thermal denaturation curves. The methods gave equivalent results, deltaCp = 1.15+/-0.08 kcal mol(-1) K(-1). Estimates of the conformational stability of ribonuclease A based on these results from thermal unfolding are in good agreement with estimates from urea unfolding analyzed using the linear extrapolation method.

Anion binding to the ubiquitin molecule

Effects of different salts (NaCl, MgCl2, CaCl2, GdmCl, NaBr, NaClO4, NaH2PO4, Na2SO4) on the stability of the ubiquitin molecule at pH 2.0 have been studied by differential scanning calorimetry, circular dichroism, and Tyr fluorescence spectroscopies. It is shown that all of the salts studied significantly increase the thermostability of the ubiquitin molecule, and that this stabilization can be interpreted in terms of anion binding. Estimated thermodynamic parameters of binding for Cl- show that this binding is relatively weak (Kd = 0.15 M) and is characterized by a negative enthalpy of -15 kJ/mol per site. Particularly surprising was the observed stabilizing effect of GdmCl through the entire concentration range studied (0.01-2 M), however, to a lesser extent than stabilization by NaCl. This stabilizing effect of GdmCl appears to arise from the binding of Cl- ions. Analysis of the observed changes in the stability of the ubiquitin molecule in the presence of GdmCl can be adequately described by combining the thermodynamic model of denaturant binding with Cl- binding effects.

Sleep alterations after acute administration of carbamazepine in cats

Little is known about the effects of carbamazepine (CBZ) on sleep despite the relationship between sleep and epilepsy and the common clinical use of CBZ. As part of a larger study on sleep and interictal activity in kindled cats, we performed sleep recordings in 11 normal cats before and after acute administration of CBZ. Epidural screws (frontooccipital) and depth electrodes (amygdala and hippocampus) were implanted bilaterally for EEG recording. Supraorbital screws and neck intramuscular electrodes were inserted for EOG and EMG. Ten days after electrode implantation, recordings were made of animals for 2 consecutive nights to assess baseline sleep patterns. Before the third night, cats received a single oral dose of 100 mg CBZ. After washout, a second similar drug administration was given before the fourth night. Recordings were scored for wakefulness, stage I and II of NREM sleep, REM sleep, number of stage shifts, awakenings, and REM onsets. The administration of CBZ produced a significant decrease in duration and percentage of REM sleep (p less than 0.001) and an increase in stage I NREM (p less than 0.05). Total sleep time was increased (p less than 0.05); awakenings were shorter (p less than 0.01), and stage I episodes were longer (p less than 0.01).

Lack of correlation between activated clotting time and plasma heparin during cardiopulmonary bypass

The activated clotting time (ACT) with a Hemochron system for determining heparin requirements during cardiopulmonary bypass surgery, (CPB) accompanied by hemodilution and hypothermia was evaluated using plasma heparin levels as a standard. In 28 patients who were administered a standard heparin regimen (300 units/kg prebypass, 8000 units in the pump prime and 100 units/kg hourly during CPB) mean prebypass plasma heparin was 4 units/ml, and ACT was 493 seconds. During CPB mean plasma heparin decreased significantly (p < 0.001) to 3.1 units/ml, whereas mean ACT increased significantly (p < 0.001) to 674 seconds. The mean protamine requirement predicted from ACT was significantly higher (43%) than predicted from plasma heparin levels or actual protamine administered. The ACT neither accurately reflected plasma heparin during CPB nor predicted protamine requirements. The fixed-dose regimen employed, however, prevented both intraoperative thrombosis, assessed clinically in all patients, and clotting on six arterial line filters, as determined by scanning EM, despite wide variations in ACT and plasma heparin levels during surgery.