Guidelines on diagnosis,prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient‐intervention‐comparison‐outcome (PICO) format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.     

The therapeutics of lifestyle management on obesity

The global incidence and prevalence of obesity continue to increase, with the fastest rate of increase in the developing world. Obesity is associated with many chronic diseases including type 2 diabetes, cardiovascular disease and some cancers. Weight loss can reduce the risk of developing these diseases and can be achieved by means of surgery, pharmacotherapy and lifestyle interventions. Lifestyle interventions for prevention and treatment of obesity include diet, exercise and psychological interventions. All lifestyle interventions have a modest but significant effect on weight loss, but there is little evidence to indicate that any one intervention is more effective. There is evidence of an additive effect for adjunct therapy, and the combination of diet, exercise and behavioural interventions appears to be most effective for both the prevention and treatment of obesity.     

Standards for the development and methodology of the 2019 International Working Group on the Diabetic Foot guidelines

Diabetic foot disease is a source of major patient suffering and societal costs. Investing in evidence‐based international guidelines on diabetic foot disease is likely among the most cost‐effective forms of health care expenditure, provided the guidelines are outcome focused, evidence based, and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2019 updates are based on formulating relevant clinical questions and outcomes, rigorous systematic reviews of the literature, and recommendations that are specific, and unambiguous along with their transparent rationale, all using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. We herein describe the development of the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease, which consists of six chapters, each prepared by a separate working group of international experts. These documents provide guidelines related to diabetic foot disease on prevention; offloading; peripheral artery disease; infection; wound healing interventions; and classification of diabetic foot ulcers. Based on these six chapters, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. We believe that adoption and implementation of the 2019 IWGDF guidelines by health care providers, public health agencies, and policymakers will result in improved prevention and management of diabetic foot disease and a subsequent worldwide reduction in the patient and societal burden this disease causes.     

Developing multidisciplinary guidelines for the management of early rheumatoid arthritis

Objective: To develop an evidence based guideline, for the multidisciplinary management of early rheumatoid arthritis (RA). Methods: Recommendations were developed using both an evidence‐based approach and expert opinion. The scientific committee, composed of key members of the rheumatology multidisciplinary team used a Delphi approach to evaluate topics and standard statements, which formed the basis for developing recommendations for management of RA in the first 2 years of disease. Evidence taken from literature was used to support these recommendations. Results: 24 evidence based recommendations for the management of early RA, with a grade of recommendation from A to C, were developed. In addition an algorithm of care was designed to promote a clear multidisciplinary management pathway. A mechanism for audit was also identified. Conclusion: Involvement of the multidisciplinary rheumatology team has enabled a holistic guideline to be developed for the management of patients presenting with early RA. This guideline is based around best practice that is supported by published literature. Whilst most statements in the guideline are based on strong evidence, others have been formulated by expert consensus in the absence of data and should serve as an opportunity to improve current practice through future research and audit. The development and implementation of such a guideline should improve the care of patients with early RA. Copyright © 2007 John Wiley & Sons, Ltd.     

The effects of popular diets on type 2 diabetes management

Type 2 diabetes can be managed with the use of diabetes self‐management skills. Diet and exercise are essential segments of the lifestyle changes necessary for diabetes management. However, diet recommendations can be complicated in a world full of different diets. This review aims to evaluate the evidence on the effects of three popular diets geared towards diabetes management: low‐carbohydrate and ketogenic diet, vegan diet, and the Mediterranean diet. While all three diets have been shown to assist in improving glycaemic control and weight loss, patient adherence, acceptability, and long‐term manageability play essential roles in the efficacy of each diet.     

The 2004 Canadian recommendations for the management of hypertension: Part III--Lifestyle modifications to prevent and control hypertension

OBJECTIVE: To provide updated, evidence-based recommendations regarding the role of lifestyle modification in the treatment and prevention of hypertension. OUTCOMES: Lifestyle modification interventions including exercise, weight reduction, alcohol consumption, dietary modification, intake of dietary cations and stress management are reviewed. Antioxidants and fish oil supplements are also reviewed, although specific recommendations cannot be made at present. EVIDENCE: MEDLINE searches were conducted from January 2002 to September 2003 to update the 2001 recommendations for the management of hypertension. Supplemental searches in the Cochrane Collaboration databases were also performed. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently using prespecified levels of evidence by content and methodology experts. RECOMMENDATIONS: Key recommendations include the following: lifestyle modification should be extended to nonhypertensive individuals who are at risk for developing high blood pressure; 30 min to 45 min of aerobic exercise should be performed on most days (four to five days) of the week; an ideal body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2) should be maintained and weight loss strategies should use a multidisciplinary approach; alcohol consumption should be limited to two drinks or fewer per day, and weekly intake should not exceed 14 standard drinks for men and nine standard drinks for women; a reduced fat, low cholesterol diet that emphasizes fruits, vegetables and low fat dairy products, and maintains an adequate intake of potassium, magnesium and calcium, should be followed; salt intake should be restricted to 65 mmol/day to 100 mmol/day in hypertensive individuals and less than 100 mmol/day in normotensive individuals at high risk for developing hypertension; and stress management should be considered as an intervention in selected individuals. VALIDATION: All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Individuals with irreconcilable competing interests (declared by all members, compiled and circulated before the meeting) relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving at least 70% consensus are reported here. These guidelines will continue to be updated annually.     

Diabetes UK evidence‐based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence‐based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes‐related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non‐nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted ‘GRADE’ methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines .     

Use of basal insulin in the management of adults with type 2 diabetes: An Asia-Pacific evidence-based clinical practice guideline

The objective of this study was to provide recommendations regarding effectiveness, safety, optimal starting dose, optimal maintenance dose range, and target fasting plasma glucose of five basal insulins (glargine U-300, degludec U-100, glargine U-100, detemir, and insulin protamine Hagedorn) in insulin-naïve adult patients with type 2 diabetes in the Asia-Pacific region. Based on evidence from a systematic review, we developed an Asia-Pacific clinical practice guideline through comprehensive internal review and external review processes. We set up and used clinical thresholds of trivial, small, moderate, and large effects for different critical and important outcomes in the overall certainty of evidence assessment and balancing the magnitude of intervention effects when making recommendations, following GRADE methods (Grading of Recommendations, Assessment, Development, and Evaluation). The AGREE (Appraisal of Guidelines, Research and Evaluation) and RIGHT (Reporting Items for practice Guidelines in HealThcare) guideline reporting checklists were complied with. After the second-round vote by the working group members, all the recommendations and qualifying statements reached over 75% agreement rates. Among 44 contacted external reviewers, we received 33 clinicians' and one patient's comments. The overall response rate was 77%. To solve the four research questions, we made two strong recommendations, six conditional recommendations, and two qualifying statements. Although the intended users of this guideline focused on clinicians in the Asia-Pacific region, the eligible evidence was based on recent English publications. We believe that the recommendations and the clinical thresholds set up in the guideline can be references for clinicians who take care of patients with type 2 diabetes worldwide.     

Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta‐analysis

Lifestyle interventions addressing diet, exercise‐training, sleep hygiene, and/or tobacco/alcohol cessation are recommended in the management of obstructive sleep apnoea (OSA). Yet their effectiveness on this condition still requires further research. This systematic review and meta‐analysis was aimed at establishing (a) the effectiveness of lifestyle interventions on apnoea‐hypopnoea index (AHI), oxygen desaturation index (ODI), excessive daytime sleepiness (EDS), and secondary OSA measures among adults, and (b) which intervention characteristics may drive the greatest improvements. A systematic search of studies was conducted using CINAHL, ProQuest, Psicodoc, Scopus, and Web of Science, from inception to April 2018. Standardized mean differences were calculated using the inverse variance method and random‐effects models. The meta‐analyses of 13 randomized controlled trials and 22 uncontrolled before‐and‐after studies (1420 participants) revealed significant reductions on AHI (d = ?0.61 and ?0.46, respectively), ODI (d = ?0.61 and ?0.46) and EDS (d = ?0.41 and ?0.49). Secondary OSA outcomes were also improved after interventions. However, effectiveness of interventions differed depending on their components, OSA severity, and gender. Thus, until future research further supports the differential effectiveness among lifestyle interventions on OSA, those addressing weight loss through diet and exercise‐training may be the most effective treatments for male patients with moderate‐severe OSA.     

中国高尿酸血症与痛风诊疗指南(2019)

近年来,中国高尿酸血症与痛风患病率急剧增加,亟需制订基于国人研究证据的临床循证指南。为此,中华医学会内分泌学分会遵循国际通用GRADE分级方法,采用临床循证指南制订流程,由方法学家在内的多学科专家参与制订了本指南。本指南包含3条推荐总则和针对10个临床问题的推荐意见,涵盖了高尿酸血症与痛风的诊断、治疗和管理;首次提出了亚临床痛风、难治性痛风的概念和诊治意见;首次对碱化尿液相关问题进行了推荐;首次对痛风常见合并症药物选择进行了推荐。本指南旨在为临床医生和相关从业者对高尿酸血症与痛风的诊疗决策提供最佳依据。     

Spleen Australia guidelines for the prevention of sepsis in patients with asplenia and hyposplenism in Australia and New Zealand

People with asplenia/hyposplenism are at increased risk of fulminant sepsis, which carries a high mortality rate. A range of preventive measures is recommended although there is ongoing evidence that knowledge of and adherence to these strategies is poor. There have been significant changes in recommended vaccinations since the previously published recommendations in 2008. We provide current recommendations to help Australian and New Zealand clinicians in the prevention of sepsis in patients with asplenia and hyposplenia. The guideline includes Australian epidemiological data, preferred diagnostic techniques and recommendations for optimal antimicrobial prophylaxis and vaccination protocols.     

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.     

Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis

Aim: Physiotherapy is an integral part of the management of ankylosing spondylitis (AS) and there is a need for recommendations which focus on the rehabilitation of patients with AS. We aimed to develop recommendations for the physical therapy and rehabilitation of patients with AS based on the evidence and expertise. Methods: The Anatolian Group for the Assessment in Rheumatic Diseases (ANGARD) is a scientific group of Turkish academicians (physiatrists and rheumatologists) who are experts in the rehabilitation of patients with AS. A systematic literature search summarizing the current available physiotherapy and rehabilitation trials in AS were presented to the experts before a special 2‐day meeting. Experts attending this meeting first defined a framework based on the main principles and thereafter collectively constructed six major recommendations on physiotherapy and rehabilitation in AS. After the meeting an email survey was conducted to rate the strength of the recommendations. Results: Six key recommendations which cover the general principles of rehabilitation in AS in terms of early intervention, initial and follow‐up assessments and monitoring, contraindications and precautions, key advice for physiotherapy methods and exercise were constructed. Conclusion: These recommendations were developed using evidence‐based data and expert opinion. The implementation of these recommendations should encourage a more comprehensive and methodical approach in the rehabilitation of patients with AS. Regular lifelong exercise is the mainstay of rehabilitation and there is a considerable need for well‐designed studies which will enlighten the role of physical therapy in the management of AS.     

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee‐high offloading device is the first choice of offloading treatment. A removable knee‐high and removable ankle‐high offloading device are to be considered as the second‐ and third‐choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth‐choice offloading treatment. If non‐surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.     

Exercise for the treatment and management of overweight women with polycystic ovary syndrome: a review of the literature

Polycystic ovary syndrome (PCOS) is characterized by the presence of polycystic ovaries, menstrual dysfunction, infertility and biochemical and clinical hyperandrogenism and is associated with an increased prevalence of cardiometabolic risk factors and psychological problems. Despite the well‐established benefits of exercise training and its recommendation as a cornerstone of PCOS management, few well‐controlled randomized studies have been conducted evaluating the benefits of exercise training and specific exercise regimes in women with PCOS. From the limited studies there appears to be a beneficial effect of exercise either alone or in combination with energy restriction has shown to improve fitness, cardiovascular, hormonal, reproductive and psychological outcomes. While the addition of regular exercise to energy restriction appears to only have additional benefits for improving body composition, these greater improvements are likely to have long‐term implications. While lifestyle modification including regular exercise appears to be an effective strategy for the management of overweight PCOS women, methodological limitations in the studies limit the generalizability of the findings. Future research with rigorous study designs is needed to determine specific exercise guidelines that will provide the greatest benefit for these women.     

New guidelines for the management of adult community-acquired pneumonia

PURPOSE OF REVIEW: Community-acquired pneumonia is a major cause of morbidity and mortality, and is the leading cause of death from an infectious disease. International societies have published and revised guidelines aiming to improve the management of adult community-acquired pneumonia, based on the best available evidence. The aim of this review is to compare the current guideline recommendations. RECENT FINDINGS: Aspects of guidelines differ based on local factors including resources and antimicrobial factors, as well as the differences in interpretation of existing evidence. SUMMARY: The lack of robust evidence behind aspects of guideline recommendations as well as the lack of adherence to published guidelines both need to be addressed if the management of community-acquired pneumonia is to be improved.     

Effective strategies for weight loss in post‐partum women: a systematic review and meta‐analysis

Post‐partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post‐partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post‐partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self‐monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home‐ or centre‐based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta‐analysis (1,892 women, age 24–36 years). Studies with self‐monitoring had significantly greater weight lost than those without (?4.61 kg [?7.08, ?2.15] vs. ?1.34 kg [?1.66, ?1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (?3.24 kg [?4.59, ?1.90] vs. ?1.63 kg [?2.16, ?1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self‐monitoring and take a combined diet‐and‐exercise approach have significantly greater weight loss in post‐partum women.     

Secondary prevention for patients following a myocardial infarction: summary of NICE guidance

Mortality from coronary heart disease has been falling in the UK since the 1970s, but remains higher than in most other Western countries. Most patients receive some treatment for secondary prevention after myocardial infarction, but not all patients are offered the most effective secondary prevention package. The recently published NICE guideline for secondary prevention in patients after myocardial infarction, summarised in this article, makes clear recommendations for management of patients after myocardial infarction, based on best available evidence. The guidelines update the 2001 NICE guideline, and have expanded and emphasised the recommendations for physical activity, dietary and other lifestyle changes, and cardiac rehabilitation, and updated the recommendations for drug therapy.     

Misconceptions, challenges, uncertainty, and progress in guideline recommendations

Although the quality of clinical practice guidelines has improved over the last decade, current guideline systems have limitations that reduce their validity and limit their acceptance. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group, a worldwide collaboration of guideline developers, methodologists, and clinicians, has constructed a system for developing guidelines that addresses these shortcomings. The system includes a transparent and rigorous methodology for rating the quality of evidence, an explicit balancing of benefits and harms of healthcare interventions, an explicit acknowledgement of the values and preferences that underlie the recommendations, and whether the intervention represents a wise use of resources. These four elements determine whether a recommendation is strong or weak. A guideline panel offers strong recommendations when virtually all informed patients would choose the same management strategy. Weak recommendations imply that choices will differ across the range of patient values and preferences. The GRADE system has been tested in multiple practice settings and for a large spectrum of questions, refined and re-evaluated to ensure that it captures the complex issues involved in evidence assessment and grading recommendations while maintaining simplicity and practicality. Many guideline organizations and medical societies have endorsed the system and adopted it for their guideline processes.     

Stroke management: updated recommendations for treatment along the care continuum

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.