A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach

An increasing number of organizations worldwide are using new and improved standards for developing trustworthy clinical guidelines. One of such approaches, developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group, offers systematic and transparent guidance in moving from evidence to recommendations. The GRADE strategy concentrates on four factors: the balance between benefits and harms, the certainty of the evidence, values and preferences, and resource considerations. However, it also considers issues around feasibility, equity, and acceptability of recommendations. GRADE distinguishes two types of recommendations: strong and weak. Strong recommendations reflect a clear preference for one alternative and should apply to all or almost all patients, obviating the need for a careful review of the evidence with each patient. Weak recommendations are appropriate when there is a close balance between desirable and undesirable consequences of alternative management strategies, uncertainty regarding the effects of the alternatives, uncertainty or variability in patients' values and preferences, or questionable cost-effectiveness. Weak recommendations usually require accessing the underlying evidence and a shared decision-making approach. Clinicians using GRADE recommendations should understand the meaning of the strength of the recommendation, be able to critically appraise the recommendation, and apply trustworthy recommendations according to their strength.     

Effects of Tai Chi Yunshou on upper-limb function and balance in stroke survivors: A systematic review and meta-analysis

Background and purposePhysical rehabilitation plays an important role in the recovery of motor function after a stroke. This study aimed to evaluate the effects of Tai Chi Yunshou (TCY), a form of physical therapy, on upper-limb function and balance in stroke survivors.MethodsMEDLINE, Embase, CENTRAL and five Chinese databases were retrieved from inception to July 1, 2020 (updated on March 31, 2022). Randomized controlled trials of TCY versus no-treatment for stroke were included. The RoB-2 was used to evaluate the quality of included studies. Upper-limb motor impairment, balance, and activities of daily living (ADLs) were measured by Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), Berg Balance Scale (BBS), and Barthel Index (BI), respectively. Data synthesis was performed using RevMan (v5.3), and expressed as mean difference (MD) with 95% confidence intervals (CI).ResultsSeven studies with 529 participants were included. Compared with no-treatment, TCY improved FMA-UE (MD = 7.31, 95% CI: 5.86–8.77, minimal clinically important difference [MCID]: 9–10), BBS (MD = 4.68, 95% CI: 0.28–9.07, MCID: 4), and BI (MD = 4.12, 95% CI: 3.28–4.96, MCID: 1.85) in stroke survivors.ConclusionTCY may benefit balance and ADLs in rehabilitation after a stroke, but it may not improve upper-limb function clinically.     

Case report: sternal fracture from a seatbelt

We report a case of a sternal fracture in a patient restrained by a seatbelt on the passenger side of a car in a moderate-speed motor vehicle accident. This patient apparently did not have contact with any fixed part of the car. In reporting this case it is our intention to demonstrate that the increased use of seatbelts, although life-saving in many ways, may be associated with emergence of a new spectrum of less “life-threatening” injuries associated with their use. We, therefore, make a case for increased search for sternal injuries and potential complications (including cardiac) for restrained passengers without evidence of other direct chest trauma. We believe that although seatbelts are an essential part of passenger car safety, their use should not deter extensive investigation when evaluating the emergency patient for injuries usually associated with the unrestrained passenger.     

Communicating to promote informed decisions in the context of early pregnancy loss

ObjectiveTo evaluate residents’ ability to engage standardized patients in informed decision making during a pregnancy loss scenario.MethodsForty patient encounters between interns and standardized patients were coded to assess informed decision-making practices, exploration of unexpressed concerns, and support provision.ResultsInterns engaged in minimum informed decision making but did not address all of the communicative elements necessary for informed decisions, and most elements were only partially addressed. Patients in this study did not receive information about all management options, their concerns were not addressed, and there was limited support communicated for their decision.ConclusionThis study offers an initial assessment of a communicative approach to evaluate and improve decision making during early pregnancy loss. A comprehensive approach to making informed decisions must include discussion of all management options, exploration of patient preferences and concerns, and support for the patient’s decision.Practice implicationsPhysicians could benefit from communication skills training to communicate more effectively with patients to help them make more informed decisions.     

The Effect of Statins on Acute and Long-Term Outcome After Ischemic Stroke in the Elderly

BackgroundAlthough treatment with statins has produced beneficial effects when used as secondary prevention, its primary protective role is still somewhat controversial. Moreover, few studies have evaluated the effect of statins in older patients with stroke.ObjectiveThe aim was to investigate whether treatment with statins decreases stroke severity and/or improves survival and outcome after stroke in an older population.MethodsWe investigated the association between previous statin use and stroke severity (National Institutes of Health Stroke Scale [NIHSS]), as well as the effect of poststroke statin treatment on 12-month functional outcome (modified Rankin Scale [mRS] score) in 799 patients (mean age, 78 years), with acute ischemic stroke. The effect of statin treatment on survival was examined using the Cox proportional hazard model, after adjusting for relevant covariates.ResultsStatins did not decrease stroke severity and did not improve 30-day survival. However, both the 12-month survival (hazard ratio = 0.33; 95% CI, 0.20–to 0.54; P < 0.001) and the 12-month functional outcome (odds ratio = 2.09; 95% CI, 1.25–3.52; P = 0.005) were significantly better in the group treated with statins.ConclusionsSignificantly better survival and functional outcome were noted with poststroke statins at the end of the 12-month follow-up period. Statins seem to provide beneficial effects for the long-term functional outcome and survival in the elderly.     

养心定悸胶囊临床研究概况及可视化分析

[目的]系统分析养心定悸胶囊临床研究概况、研究热点及趋势,为药品临床价值定位与二次开发、指导临床研究提供参考。[方法]系统检索养心定悸胶囊的临床研究,采用文献计量学方法及VOSviewer软件对研究机构、作者、关键词、研究特征等进行可视化分析,并绘制可视化图谱。[结果]共纳入文献39篇,均为临床对照试验设计类型,共包括25个实施单位,以河北省内三级医疗机构为主;涉及183个关键词,主要围绕其优势适应病症(心律失常、室性早搏、心悸);治疗组干预方式均为西医常规加载治疗,临床结局主要关注临床有效率、心功能指标、实验室指标和不良事件等。[结论]养心定悸胶囊临床研究热点突出,目标集中,需进一步加强机构间的合作交流,重视研究实施过程的质量控制,提高研究质量与价值。