Interventional Therapy Versus Medical Therapy for Secundum Atrial Septal Defect: A Systematic Review (Part 2) for the 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Secundum atrial septal defect (ASD) is the most common adult congenital heart defect and can present with wide variation in clinical findings. With the intention of preventing morbidity and mortality associated with late presentation of ASD, consensus guidelines have recommended surgical or percutaneous ASD closure in adults with right heart enlargement, with or without symptoms. The aim of the present analysis was to determine if the protective effect of secundum ASD closure in adults could be qualified by pooling data from published studies.A systematic review and meta-analysis were performed by using EMBASE, MEDLINE (through PubMed), and the Cochrane Library databases to assess the effect of secundum ASD percutaneous or surgical closure in unoperated adults ≥18 years of age. Data were pooled across studies with the DerSimonian-Laird random-effects model or a Bayesian meta-analysis model. Between-study heterogeneity was assessed with Cochran’s Q test. Bias assessment was performed with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool, and statistical risk of bias was assessed with Begg and Mazumdar’s test and Egger’s test.A total of 11 nonrandomized studies met the inclusion criteria, contributing 603 patients. Pooled analysis showed a protective effect of ASD closure on New York Heart Association functional class and on right ventricular systolic pressure, volumes, and dimensions. Two additional studies comprising 652 patients were reviewed separately for mortality outcome and primary outcome of interest because they did not meet the inclusion criteria. Those studies showed that ASD closure was associated with a weak protective effect on adjusted mortality rate but no significant impact on atrial arrhythmias in patients >50 years of age. Across all studies, there was significant heterogeneity between studies for nearly all clinical outcomes. The overall body of evidence was limited to observational cohort studies, the limitations of which make for low-strength evidence. Even within the parameters of the included studies, quality of evidence was further diminished by the lack of well-defined clinical outcomes.In conclusion, pooled data analysis on the impact of secundum ASD closure in adults was notably limited because of the lack of randomized controlled trials in patients with only secundum ASD. The few cohort studies in this population demonstrated improvement in functional status and right ventricular size and function as shown by echocardiogram. However, our findings suggest that at the time of this publication, insufficient data are available to determine the impact of ASD repair on mortality rate in adults.     

Judicial handling of cases of non-accidental head trauma in infants: Review and analysis of expert assessments

IntroductionGood practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis.The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI.MethodA retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis.ResultsIn our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases.ConclusionOur study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.     

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BackgroundIntegration of specialist palliative care into routine oncologic care improves patients’ quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of “palliative care” and “hospice care” in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.Materials and MethodsWe reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of “palliative care” and “hospice care,” the definitions for these terms if available, and the recommended timing for these services.ResultsWe identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.Conclusion“Palliative care” was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.Implications for PracticeIntegration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.     

Therapeutic approaches of German and Turkish physicians to rheumatoid arthritis and to osteoarthritis of the knee

Summary Our objective was to compare the therapeutic approaches of German and Turkish physicians to rheumatoid arthritis (RA) and to osteoarthritis (OA) of the knee, by means of a mailed survey. The survey contained four case histories representing a mild, a moderate and a severe case of RA and a case of OA of the knee. One hundred and thirty-two physicians from Germany (internal medicine based (IR) and orthopaedics based (OR) rheumatologists) and thirty-three from Turkey (rheumatologists and physical medicine and rehabilitation specialists (PT) participated in the study.German respondents would give more disease-modifying drugs (DMARD) in early RA (48.7% vs 18.2%, p<0.05), whereas their Turkish colleagues would prescribe more analgesics, ultrasound and kryotherapy in OA of the knee (63.6% vs 22.1%, 30.3% vs 6.5% and 24.2% vs 0.0% respectively p<0.05). German physicians chose more exercise, physical and occupational therapy, radiation synovectomy and surgery in all cases. In OA of the knee German OR's would recommend less analgesics, but more local steroids, chondroprotective agents and surgery than the other groups.We may conclude that clinical practice of RA and OA of the knee differs considerably in Germany and Turkey. Cultural, social, educational and economic factors could influence the decisions of the physicians.     

当前我国部分地区稳定性劳力型心绞痛治疗方式的调查

目的　抽样调查我国部分地区稳定性劳力型心绞痛患者的人口统计学特征及治疗方式。方法　为 4周前瞻性调查 ,每研究单位入选 1 0～ 30例连续的稳定性劳力型心绞痛门诊患者参加本研究 ,在 4周调查期内随访 2次。结果　 96 3例患者入选本研究 ,其中 91 0 %应用抗血小板药或抗凝药 ,90 7%应用长效硝酸酯类 ,6 8 3%应用 β受体阻滞剂 ,6 3 3%应用调脂药 ,5 1 5 %应用血管紧张素转换酶抑制剂 (ACEI) ,5 0 9%应用钙拮抗剂和 36 2 %应用曲美他嗪。在最近一次随访时 ,伴随高血压的患者血压未达目标水平 [<1 4 0 /90mmHg (1mmHg =0 1 33kPa) ]者占 86 3%,总胆固醇(TC)未达目标水平 (4 6 8mmol/L)者占 73 5 %,低密度脂蛋白胆固醇 (LDL C)未达目标水平 (2 6 0mmol/L)者占 6 5 8%。结论　虽然近年来我国在稳定性劳力型心绞痛的治疗方面基本遵循了国际上公认的指南 ,但在控制高血压和高胆固醇血症等危险因素方面仍存在较大差距。