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A partnership model for capacity-building of primary care physicians in evidence-based management of diabetic retinopathy in India.
Bhalla, S, Soni, T, Joshi, M, Sharma, VK, Mishra, R, Mohan, V, Unnikrishnan, R, Kim, R, Murthy, GVS, Prabhakaran, D, et al
Indian journal of ophthalmology. 2020;(Suppl 1):S67-S69
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Abstract
In India, more than 72 million people have diabetes. Diabetic retinopathy (DR), a vision-threatening complication of people with diabetes, is an important cause of avoidable blindness. The delay in the detection of DR is due to lack of awareness and shortage of ophthalmologists trained in the management of DR. With this background, in 2015, we initiated a capacity-building program "Certificate Course in Evidence Based Management of Diabetic Retinopathy (CCDR)" with an objective to build the skills and core competencies of the physicians across India in the management of diabetes and DR. The program has completed four cycles and 578 physicians have been trained. The course elicited an excellent response, which reflects the much-felt need for skill improvement in DR diagnosis and management for physicians in India. This model demonstrates an innovative modality to address DR-related avoidable blindness in a resource-restraint country like India.
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Nutritional Approaches for the Management of Nonalcoholic Fatty Liver Disease: An Evidence-Based Review.
Parra-Vargas, M, Rodriguez-Echevarria, R, Jimenez-Chillaron, JC
Nutrients. 2020;(12)
Abstract
Nonalcoholic fatty liver disease (NAFLD) is on the rise worldwide representing a public health issue. Its coexistence with obesity and other metabolic alterations is highly frequent. Therefore, current therapy interventions for NAFLD are mainly focused on progressive weight loss through modulation of overall calorie intake with or without specific macronutrient adjustments. Furthermore, other relevant nutritional interventions are built on food selection and time-restricted eating. Since every strategy might bring different results, choosing the optimal diet therapy for a patient is a complicated task, because NAFLD is a multifactorial complex disease. Importantly, some factors need to be considered, such as nutrition-based evidence in terms of hepatic morphophysiological improvements as well as adherence of the patient to the meal plan and adaptability in their cultural context. Thus, the purpose of this review is to explore and compare the subtleties and nuances of the most relevant clinical practice guidelines and the nutritional approaches for the management of NAFLD with a special attention to tangible outcomes and long-term adherence.
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Treatment Modalities for Cherry Angiomas: A Systematic Review.
Buslach, N, Foulad, DP, Saedi, N, Mesinkovska, NA
Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2020;(12):1691-1697
Abstract
BACKGROUND Cherry angiomas are benign vascular proliferations of endothelial cells associated with aging. Currently, no mainstay of treatment for these vascular anomalies exists. OBJECTIVE To review existing evidence-based therapies for the treatment of cherry angiomas. METHODS A literature search in May 2019 was performed with PubMed Database and Cochrane Library using the following terms: "cherry angioma," "senile hemangioma," "senile angioma," "cherry hemangioma," and "Campbell de Morgan spots." RESULTS Ten studies included in this systematic review reported laser therapy and nonlaser therapy as efficacious treatments for cherry angiomas. Among the laser therapies, pulsed dye laser (PDL) was preferred over potassium-titanyl-phosphate (KTP) and electrodessication (ED), based on decreased procedure-related pain. The neodymium-doped yttrium aluminum garnet (Nd:YAG) laser 1064 nm produced less pigmentary complications, whereas KTP and PDL risked pigmentary changes in darker-skinned individuals. Nonlaser therapies included cryotherapy, sclerotherapy, electrosurgery (i.e., ED, electrocoagulation), and radiofrequency ablation. No therapy proved to be superior. CONCLUSION A variety of therapeutic modalities exist for the treatment of cherry angiomas. However, a limited number of high-quality studies explored the efficacy of treatments and compared treatment modalities. Light-based methods such as argon, KTP, Nd:YAG, intense pulsed light, and PDL, along with non-light-based interventions such as cryotherapy, electrosurgery, and sclerotherapy effectively treated cherry angiomas.
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Walking for subjects with type 2 diabetes: A systematic review and joint AMD/SID/SISMES evidence-based practical guideline.
Moghetti, P, Balducci, S, Guidetti, L, Mazzuca, P, Rossi, E, Schena, F, , , , , ,
Nutrition, metabolism, and cardiovascular diseases : NMCD. 2020;(11):1882-1898
Abstract
AIMS: Regular exercise is considered a cornerstone in the management of type 2 diabetes mellitus (T2DM). It improves glucose control and cardiovascular risk factors, contributes to weight loss, and also improves general well-being, likely playing a role in the prevention of chronic complications of diabetes. However, compliance to exercise recommendations is generally inadequate in subjects with T2DM. Walking is the most ancestral form of physical activity in humans, easily applicable in daily life. It may represent, in many patients, a first simple step towards lifestyle changes. Nevertheless, while most diabetic patients do not engage in any weekly walking, exercise guidelines do not generally detail how to improve its use. The aims of this document are to conduct a systematic review of available literature on walking as a therapeutic tool for people with T2DM, and to provide practical, evidence-based clinical recommendations regarding its utilization in these subjects. DATA SYNTHESIS Analysis of available RCTs proved that regular walking training, especially when supervised, improves glucose control in subjects with T2DM, with favorable effects also on cardiorespiratory fitness, body weight and blood pressure. Moreover, some recent studies have shown that even short bouts of walking, used for breaking prolonged sitting, can ameliorate glucose profiles in diabetic patients with sedentary behavior. CONCLUSIONS There is sufficient evidence to recognize that walking is a useful therapeutic tool for people with T2DM. This document discusses theoretical and practical issues for improving its use. This article is co-published in the journals Sport Sciences for Health and Nutrition, Metabolism and Cardiovascular Diseases.
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Problems lowering the study quality in traditional medicine, introspection from an example of meta-analysis of acupuncture.
Chen, Q, Wang, Q, Ding, S, Li, S, Zhang, Y, Chen, S, Lin, X, Li, C, Asakawa, T
BMC complementary medicine and therapies. 2020;(1):41
Abstract
BACKGROUND Most randomized controlled trials (RCTs) of traditional medicine (such as traditional Chinese medicine (TCM), psychotherapy or behavioral therapy, and dietary interventions, etc.) have reported that they could not provide convincing evidence to support the efficacy because of the low quality of their studies. Here, we aimed to determine the underlying problems of the study quality using standards of evidence-based medicine (EBM) to evaluate the efficacy of traditional medicine. METHODS We conducted an example of meta-analysis to evaluate the efficacy of acupuncture, a classical treatment of TCM, for treatment of intracerebral hemorrhage (ICH). The quality of the included studies was evaluated by using a Jadad score. RESULTS A total of 24 Chinese RCTs that enrolled 1815 patients with ICH were included. Although the results suggested that acupuncture had good efficacy for relief of neurological deficits and improvement of the activities of daily living despite the high heterogeneity of the included studies, the low quality of the included literature reduced the worthiness of the evidence. Two systematic problems (lack of blinding and allocation concealment and high heterogeneity) and one non-systematic problem (lack of reports on adverse events and follow-up) of the TCM studies were found in this illustrational meta-analysis. We believed that other interventions of traditional medicine also suffer from these problems. CONCLUSIONS Non-systematic problems can be improved by perfecting the experimental design, educating the researcher, and improving the reporting system. However, systematic problems are derived from the characteristics of traditional medicine that are difficult to be corrected. We propose that adoption of objective indexes might be a better solution to improve the systematic problems of traditional medicine. We summarized the problems and the underlying solutions, which may contribute to improve the study quality of systematic review in traditional medicine, strictly complying with the principles of EBM.
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Therapeutic Aspects of Squill; An Evidence-Based Review.
Saket, K, Afshari, JT, Saburi, E, Yousefi, M, Salari, R
Current drug discovery technologies. 2020;(3):318-324
Abstract
From ancient times, medicinal plants have been usually utilized to treat many disorders, but today, interest in these herbs is again aroused, because of their fewer side effects and low-cost. In traditional medicine, for many diseases, various medicinal herbs have been suggested so far. Drimia maritime, also named squill, is an important medicinal plant for the treatment of many diseases, especially respiratory diseases. In the current evidence-based study, we conducted a review of the general characteristics, ingredients, administration form, and side effects of squill in traditional medicine. For this purpose, traditional Persian medicine literatures and electronic databases were examined including PubMed, Scopus, and Google Scholar. Many compounds are isolated from D.maritima, including scillaren, scillirubroside, scillarenin, and bufadienolide glycosides. Oxymel is the most commonly used form of squill for various diseases, especially respiratory diseases. Besides, squill has been used in the treatment of cardiovascular, digestive, and dermatological disorders, it is also used against various cancer cells for its antioxidant and cytotoxic properties. Moreover, there is relatively reliable evidence of its benefits for bacterial and helminthic infections, rheumatism, edema, gout, abortion induction, healing of wounds and urine induction. It seems that supplementary studies are required to explore the bioactive agents and their effective mechanisms.
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Evidence-Based Data About Prevalence and Risk of Malignancy of Thyroid Incidentalomas Detected by Different PET Radiopharmaceuticals.
Signore, G, Albano, D, Giovanella, L, Bertagna, F, Treglia, G
Current radiopharmaceuticals. 2020;(2):89-93
Abstract
BACKGROUND To date, several meta-analyses and systematic reviews have reported data about the prevalence and risk of malignancy of thyroid incidentalomas detected by different PET radiopharmaceuticals. OBJECTIVE This article aims to summarize the published evidence-based data about the prevalence and risk of malignancy of thyroid incidentalomas detected by different PET radiopharmaceuticals. METHODS A comprehensive computer literature search of systematic reviews and meta-analyses published up to July 2019 in PubMed/MEDLINE and Cochrane library databases regarding the prevalence and risk of malignancy of thyroid incidentalomas detected by different PET radiopharmaceuticals was carried out. RESULTS We have summarized the data about prevalence and risk of malignancy of thyroid incidentalomas detected by different PET radiopharmaceuticals (fluorine-18 fluorodeoxyglucose, radiolabelled choline and prostate-specific membrane antigen) taking into account 8 evidence-based articles. CONCLUSION Evidence-based data demonstrated that thyroid incidentalomas detected by different PET radiopharmaceuticals are not infrequent and their risk of malignancy is not negligible, in particular if focal pattern is evident at PET, thus requiring further clinical and instrumental evaluation.
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An adaptable implementation package targeting evidence-based indicators in primary care: A pragmatic cluster-randomised evaluation.
Willis, TA, Collinson, M, Glidewell, L, Farrin, AJ, Holland, M, Meads, D, Hulme, C, Petty, D, Alderson, S, Hartley, S, et al
PLoS medicine. 2020;(2):e1003045
Abstract
BACKGROUND In primary care, multiple priorities and system pressures make closing the gap between evidence and practice challenging. Most implementation studies focus on single conditions, limiting generalisability. We compared an adaptable implementation package against an implementation control and assessed effects on adherence to four different evidence-based quality indicators. METHODS AND FINDINGS We undertook two parallel, pragmatic cluster-randomised trials using balanced incomplete block designs in general practices in West Yorkshire, England. We used 'opt-out' recruitment, and we randomly assigned practices that did not opt out to an implementation package targeting either diabetes control or risky prescribing (Trial 1); or blood pressure (BP) control or anticoagulation in atrial fibrillation (AF) (Trial 2). Within trials, each arm acted as the implementation control comparison for the other targeted indicator. For example, practices assigned to the diabetes control package acted as the comparison for practices assigned to the risky prescribing package. The implementation package embedded behaviour change techniques within audit and feedback, educational outreach, and computerised support, with content tailored to each indicator. Respective patient-level primary endpoints at 11 months comprised the following: achievement of all recommended levels of haemoglobin A1c (HbA1c), BP, and cholesterol; risky prescribing levels; achievement of recommended BP; and anticoagulation prescribing. Between February and March 2015, we recruited 144 general practices collectively serving over 1 million patients. We stratified computer-generated randomisation by area, list size, and pre-intervention outcome achievement. In April 2015, we randomised 80 practices to Trial 1 (40 per arm) and 64 to Trial 2 (32 per arm). Practices and trial personnel were not blind to allocation. Two practices were lost to follow-up but provided some outcome data. We analysed the intention-to-treat (ITT) population, adjusted for potential confounders at patient level (sex, age) and practice level (list size, locality, pre-intervention achievement against primary outcomes, total quality scores, and levels of patient co-morbidity), and analysed cost-effectiveness. The implementation package reduced risky prescribing (odds ratio [OR] 0.82; 97.5% confidence interval [CI] 0.67-0.99, p = 0.017) with an incremental cost-effectiveness ratio of £1,359 per quality-adjusted life year (QALY), but there was insufficient evidence of effect on other primary endpoints (diabetes control OR 1.03, 97.5% CI 0.89-1.18, p = 0.693; BP control OR 1.05, 97.5% CI 0.96-1.16, p = 0.215; anticoagulation prescribing OR 0.90, 97.5% CI 0.75-1.09, p = 0.214). No statistically significant effects were observed in any secondary outcome except for reduced co-prescription of aspirin and clopidogrel without gastro-protection in patients aged 65 and over (adjusted OR 0.62; 97.5% CI 0.39-0.99; p = 0.021). Main study limitations concern our inability to make any inferences about the relative effects of individual intervention components, given the multifaceted nature of the implementation package, and that the composite endpoint for diabetes control may have been too challenging to achieve. CONCLUSIONS In this study, we observed that a multifaceted implementation package was clinically and cost-effective for targeting prescribing behaviours within the control of clinicians but not for more complex behaviours that also required patient engagement. TRIAL REGISTRATION The study is registered with the ISRCTN registry (ISRCTN91989345).
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Icosapent ethyl: Where will it fit into guideline-based medical therapy for high risk atherosclerotic cardiovascular disease?
Orringer, CE
Trends in cardiovascular medicine. 2020;(3):151-157
Abstract
Patients who are at high or very high risk for atherosclerotic cardiovascular disease (ASCVD) events derive the greatest benefit when clinicians prescribe evidence-based preventive therapies. The writing process used in the creation of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol employed a thorough evaluation of the highest quality evidence, and synthesis of this evidence into actionable recommendations for ASCVD risk reduction. Clinical trials supporting the addition of ezetimibe, PCSK9 inhibitors, or both to evidence-based statins provide the basis for the updated recommendations for the preventive care of these patients. The publication in late 2018 of a randomized controlled trial supporting the net ASCVD risk reduction benefit of adding icosapent ethyl to statins in selected hypertriglyceridemic patients with clinical ASCVD and/or type 2 diabetes with multiple additional risk markers provides the rationale for incorporation of icosapent ethyl therapy into future ASCVD preventive care regimens.
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A Review on Evidence-Based Treatments for Meibomian Gland Dysfunction.
Lam, PY, Shih, KC, Fong, PY, Chan, TCY, Ng, AL, Jhanji, V, Tong, L
Eye & contact lens. 2020;(1):3-16
Abstract
OBJECTIVES To evaluate recent studies on available therapies for meibomian gland dysfunction (MGD). METHODS A literature search on recent publications, within the last five years, concerning treatment options for MGD was performed. RESULTS A total of 35 articles were reviewed after curation by the authors for relevance. In general, all modalities of treatments were shown to have clinical efficacy in alleviating dry eye signs and symptoms, although the extent of improvement and persistency of outcomes varied between the different treatments. Evidence from published studies demonstrate that thermal pulsation produces the longest lasting effect per treatment, but it also incurs the highest per-treatment cost. Reusable methods for warm compress with lipid/semi-fluorinated alkane-containing eye drops are recommended as first-line treatment for mild-to-moderate dry eye patients, because this option is most technically feasible and cost-effective in clinical practice. Intense pulsed light (IPL) therapy and thermal pulsation may be suitable as second line for patients unresponsive to warm compress therapy; however, their respective limitations need to be considered. For refractory MGD with features of periductal fibrosis or severe blepharitis, supplementary treatment with meibomian gland probing or oral antibiotics may be used. CONCLUSIONS All eight forms of treatments, including self-applied eyelid warming, thermal pulsation, IPL, MG probing, antibiotics, lipid-containing eye drops, and perfluorohexyloctane, were effective against MGD, although with varying extent of clinical improvements. A better understanding on the mechanisms of actions may guide physicians to make better treatment decisions targeting the root causes.