Adjunct therapies after botulinum toxin injections in spastic adults: Systematic review and SOFMER recommendations

BackgroundAdjunct therapies (ATs) may further improve outcomes after botulinum toxin injections in spastic patients, but evidence was unclear in previous systematic reviews.ObjectiveTo assess the efficacy of non-pharmacological ATs in spastic adults according to the International Classification of Functioning, Disability and Health and build an expert consensus-based on a Delphi process.MethodsFour electronic databases were searched up to May 2020 for reports of comparative trials of non-pharmacologic ATs after botulinum toxin injections in spastic adults. Then, 25 French experts participated in a two-round Delphi process to build recommendations on the use of ATs.ResultsWe included 32 studies (1202 participants, median 32/study) evaluating the effects of physical agents (n = 9), joint posture procedures (JPPs, n = 11), and active ATs (n = 14), mainly after stroke. The average quality of articles was good for randomised controlled trials (median [interquartile range] PEDro score = 7 [6–8]) but moderate (n = 2) or poor (n = 2) for non-randomised controlled trials (Downs & Black checklist). Meta-analysis was precluded owing to the heterogeneity of ATs, control groups and outcome measures. There is evidence for the use of JPPs except low-dose manual stretching and soft posture techniques. Continuous postures (by taping or casting) are recommended; discontinuous postures (by orthosis) may be preferred in patients with active function. Device-free or device-assisted active ATs may be beneficial in the mid-term (> 3 months after botulinum toxin injections), particularly when performed at a high-intensity (> 3 h/week) as in constraint-induced movement therapy. Self-rehabilitation remains understudied after a focal treatment, but its interest is highlighted by the experts. The use of physical agents is not recommended.ConclusionsJPPs and active ATs (device-assisted or device-free) may further improve impairments and activities after botulinum toxin injections. Further studies are needed to better define the best strategies for ATs as a function of the individual treatment goals, participation and quality of life.Review RegistrationPROSPERO (CRD42018105856).     

Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators

Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.     

Development of a core outcome set for venous leg ulceration (CoreVen) research evaluations (protocol)

BackgroundA venous leg ulcer is a chronic leg wound caused by poor venous blood circulation in the lower limbs. It is a recurring condition causing pain, malodour, reduced mobility, and depression. Randomised controlled trials evaluating treatments for venous leg ulcers provide important evidence to inform clinical decision-making. However, for findings to be useful, outcomes need to be clinically meaningful, consistently reported across trials, and fully reported. Research has identified the large number of outcomes reported in venous leg ulcer trials, impacting both synthesis of results, and clinical decision-making. To address this, a core outcome set will be developed. A core outcome set is an agreed standardised set of outcomes which should be, as a minimum, measured and reported in all trials which evaluate treatment effectiveness for a given indication. A core outcome set has the potential to reduce research waste, improve the utility of RCTs, reduce reporting bias, facilitate treatment comparisons across different sources of evidence and expedite the production of systematic reviews, meta-analyses and evidence-based clinical guidelines.AimThe aim of this project is to develop a core outcome set for research evaluating the effectiveness of interventions for treating venous leg ulceration.MethodsThrough a scoping review of the literature on venous leg ulceration, we will firstly identify a list of candidate outcome domains (broad categories in relation to what is being measured) from randomised controlled trials and qualitative research, and outcomes (specific methods in relation to what is being measured). In two further stages, we will use the resulting lists of outcome domains and outcomes to design two online surveys. A range of stakeholders will be invited to participate in the surveys and they will be asked to indicate which outcome domains and outcomes are most important and should be considered as core in future research reports.     

德尔菲法在中医临床证候应用中的系统评价＊

目的 系统评价德尔菲法在中医临床证候应用中的应用现状，为后续规范与完善证候研究方法提供参考。方法 计算机检索五大数据库关于中医临床证候研究中应用德尔菲法的研究，检索时限自建库至2021年6月1日，由两名研究人员独立进行文献筛选、质量评估和资料提取，对质量A级和B级的研究进行分析。结果 经过质量评价共纳入201篇文献，其中原始研究199篇，方法学研究9篇。研究方向包括候分布特点、证候诊断标准、单一证候研究、证候要素研究、证候变化规律等八类。192篇文献对德尔菲法具体实施进行报道。结论 中医临床证候研究中德尔菲法应用整体较为科学，但在证候研究细节实施尚有不足，有待形成符合中医证候特色的德尔菲法标准规范临床应用。     

基于零缺陷管理理论构建肝胆外科加速康复评价指标体系

目的构建适用于肝胆外科的加速康复评价指标体系,为加速康复外科实施效果提供评价工具。方法在零缺陷管理理论基础上,通过文献查阅、德尔菲专家咨询法构建肝胆外科加速康复评价指标体系。结果 2轮问卷回收率均为100%,专家权威系数分别为0.920、0.919。经过2轮专家咨询,最终构建的肝胆外科加速康复评价指标体系包括3个一级指标,8个二级指标,39个三级指标;指标重要性评分均4分,变异系数0～0.166;并确定各级指标权重。结论肝胆外科加速康复评价指标体系构建合理,有较好的可信度,经验证后可作为肝胆外科加速康复质量评价工具。     

脑卒中个案管理师准入标准和工作职责方案的构建

目的 构建脑卒中个案管理师准入标准和工作职责,为制订符合中国国情的脑卒中个案管理师人才培养方案和工作标准提供参考依据。方法 基于文献研究、脑卒中患者管理现状调查、专家会议讨论和预咨询,构建准入标准和工作职责初稿;采用德尔菲专家咨询法,对全国8个省市的20名专家进行问卷咨询。 结果 2轮专家咨询的问卷有效回收率分别是95.2%和100.0%。第2轮咨询中,专家权威系数为0.910,准入标准和工作职责的一、二、三级指标专家意见的肯德尔和谐系数分别为0.193、0.155、0.141（P<0.05）和0.445、0.156、0.134（P<0.05）。最终形成的脑卒中个案管理师准入标准包括一级指标3项（基础条件、专业能力、综合能力）,二级指标7项,三级指标17项。工作职责包括一级指标4项（评估、计划、实施、评价）,二级指标17项,三级指标79项。 结论 经专家咨询确定的脑卒中个案管理师准入标准和工作职责方案具有较好的科学性、实用性、可行性和创新性,能为脑卒中个案管理护理实践提供理论依据。     

基于德尔菲法构建我国临床药师知识体系标准

目的：建立临床药师知识体系标准，为临床药师的培养和评估提供依据。方法：通过文献查阅，梳理出若干一级指标和二级指标；依据按Likert5级评分法设计咨询问卷；运用德尔菲法对35名专家进行两轮问卷咨询。结果：建立了包含5个一级指标，33个二级指标的临床药师知识体系标准。两轮咨询中，专家咨询积极系数分别为100%和92.9%，专家权威系数分别为0.904 3和0.907 7，专家协调系数分别为0.268和0.565。结论：专业核心知识是临床药师最应具备的知识，是临床药师培养的重中之重；临床药师的知识结构要由"以化学知识为主"转变为"以医学知识为主"；临床药师自身需要注重知识的再生，并树立终身学习的理念。本研究专家积极性和权威程度高，意见协调程度好，建立的知识体系标准能够对临床药师的培养与评估提供依据。     

An expert consensus-based guideline for the integrative anthroposophic treatment of acute gastroenteritis in children

ObjectivesAcute gastroenteritis is one of the major causes of hospital admission in childhood. The primary objective of the treatment is rehydration, but conventional drug therapies are limited. Therefore, several pediatricians supplement conventional treatment with complementary and alternative therapies. In the two German departments for pediatric integrative medicine, children suffering from an acute gastroenteritis are treated with supportive therapy based on anthroposophic medicine. However, up to now scientifically validated guidelines for these therapies are lacking.DesignWe consulted an expert pool of 50 physicians with expertise in anthroposophic medicine as well as pediatrics and invited them to participate in an online-based Delphi process. Results were analyzed by means of qualitative content analysis with two independent raters using MAXQDA. Using four rounds of questioning, a consensus-based guideline was developed.ResultsA strong consensus (>90%) or consensus (>75-90%) was achieved for 14 of 16 subsections. The guideline describes disease characteristics, the most useful diagnostics, drug as well as non-drug treatment recommendations and advises for a good physician-patient interaction.ConclusionThe guideline will help clinicians, as well as family doctors, in their daily routine and make anthroposophic medicine more tangible for parents and health insurance companies.