Leitlinien-Check für die Shuntchirurgie 2021

Zusammenfassung Fragestellung Mit dieser Übersichtsarbeit über die aktuellsten Leitlinien zur Shuntchirurgie von Patienten mit chronischer Niereninsuffizienz (NKF-KDOQI, ERBP, GEMAV und ESVS) soll unter anderem geklärt werden, ob es sinnvoll und erforderlich ist, Leitlinien für den deutschsprachigen Raum zu erarbeiten. Material und Methoden Hierfür wurden diese vier Leitlinien hinsichtlich Methodik, Themenspektrum und Evidenzlage verglichen, um Gemeinsamkeiten, Unterschiede und Besonderheiten aufzuzeigen. Sowohl die fachliche Zusammensetzung der Autorenschaft wie auch die Methodik (PICO-/GRADE-System) der einzelnen Leitlinien sind sich ähnlich. Ergebnisse Arbeitsgruppen, die viele Nephrologen im Team hatten (NKF-KDOQI, GEMAV), haben das gesamte Spektrum der Kathetereinlage in ihre Leitlinien aufgenommen. Die Leitlinien der ESVS stellen die chirurgischen Aspekte der Shuntchirurgie in den Vordergrund. In den ERBP-Leitlinien, die bei der Themenwahl auch Patientenbedürfnisse einbeziehen, ist die Fistelreifung und Kanülierung ein wichtiges Thema. Die neuen NKF-KDOQI-Leitlinien zeigen Algorithmen, wie ein individualisiertes Dialysekonzept über die Zeit aussehen könnte. Allen Leitlinien ist gemeinsam, dass viele Empfehlungen aufgrund fehlender Evidenz und fehlender aktueller Studien nur auf Expertenmeinungen beruhen. Schlussfolgerungen Die Evidenzlage muss durch neue randomisierte Studien verbessert werden. Es wäre wünschenswert, wenn mit standardisierten Verfahren und kontinuierlicher Analyse aktualisierte und online abrufbare Empfehlungen zur Verfügung stünden. Um ein solches Projekt zu realisieren, ist eine internationale Kollaboration unabdingbar. Leitlinien für den deutschsprachigen Raum würden sich so erübrigen.

A Voice Activated Video Communication System for Nurses to Communicate with COVID19 Inpatients: Notes from the Field (Preprint)

UNSTRUCTURED With the relaxing of telehealth regulations from the HIPAA Waiver for Telehealth Remote Communications during the COVID-19 Nationwide Public Health Emergency notification, our organization had the opportunity to pilot an innovative virtual care solution using a modified consumer grade system (Amazon Echo Show) within one inpatient COVID-19 unit. In this brief report, we describe our experiences with implementing the system, general feedback from clinicians, and discuss areas for future development required to enable future scaling of this solution.

A STUDY ON THE GRADE SYSTEM OF PLEADING GUILTY AND ACCEPTING PUNISHMENT—FROM THE PERSPECTIVE OF INTERSUBJECTIVITY

The right of remorse is not only the voluntary guarantee of the case of pleading guilty and accepting punishment, but also the source of the accused’s appeal. Protest is a confrontation between the right of remorse and the court of first instance’s failure to adopt the sentencing recommendation of the prosecution, and this confrontational contradiction always exists, which stems from the failure to put the characteristics of guilty plea and punishment admitting into the second instance procedure. Standardizing the right of remorse, establishing the system of cause appeal, classifying the reasons for protest and adjusting the scope of the second trial are helpful to resolve the conflicts in the system of admitting punishment and adjudication, and use intersubjectivity to break through the tension between litigation justice and litigation efficiency.

Recommendation for management of patients with their first episode of primary spontaneous pneumothorax, using video-assisted thoracoscopic surgery or conservative treatment

International guidelines do not recommend surgery for the first episode of primary spontaneous pneumothorax (PSP), except in cases of persistent air leak, hemopneumothorax, bilateral pneumothorax, or occupations at risk. However, these recommendations have been challenged because of a significant reduction in the recurrence rate in emerging studies. We evaluated the rationale of recommendations by systematically reviewing RCTs and observational studies by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. We searched articles in PubMed, EMBASE, and Cochrane databases up to August 15, 2020. The primary outcomes were the recurrence rate and complication rate. The secondary outcomes were hospital stay and drainage duration. Nine eligible studies with 1121 patients were retrieved and analyzed. The recurrence rate was lower in the VATS than in conservative treatment with moderate evidence (OR 0.13, 95% CI 0.09 to 0.19, P < 0.001, I2 = 0%). We did not find significant differences in complication rate (Peto OR 1.17, 95% CI 0.33 to 4.12, P = 0.80), hospital stay duration (MD − 0.48 days, 95% CI − 2.84 to 1.87, P = 0.69, very low evidence), and in drainage duration (MD − 3.99 days, 95% CI − 9.06 to 1.08, P = 0.12, very low evidence) between the two groups. Our results would suggest VATS treatment as a weak recommendation for patients with the first episode of PSP, based on our systematic review of the current evidence by using the GRADE system, indicating that different treatments will be appropriate for different patients and that patients’ values and preferences should be incorporated through shared decision making.Trial REGISTRY: PROSPERO; No.: CRD42020162267.

Circulating angiopoietin-like proteins in metabolic-associated fatty liver disease: a systematic review and meta-analysis

Background Angiopoietin-like proteins (ANGPTLs) are closely related to insulin resistance and lipid metabolism, and may be a key in metabolic syndrome. Non-alcoholic fatty liver disease (NAFLD) (newly named metabolic-associated fatty liver disease (MAFLD)) is based on metabolic dysfunction. There may be some correlation between ANGPTLs and MAFLD, but the specific correlation is unclear. This study aims to explore the predictive role of ANGPTLs in MAFLD and its progression. Methods Seven databases (PubMed, EMBASE, Cochrane Library, CNKI, WANFANG, CBM and Clinicaltrials.gov) were searched with free terms and MeSH terms. The random-effects model was used to pool the data, and Standardized Mean Difference (SMD) and 95% confidence intervals (CI) were taken as the overall outcome. No language restrictions existed in the article selection. RevMan 5.3, Stata 16 and MetaXL software were applied to analyse the data and the GRADE system was utilized to assess the certainty of evidence. Results After reviewing 823 related articles, 13 studies (854 cases and 610 controls) met the inclusion criteria, and contributed to this meta-analysis. The results showed that circulating ANGPTL8 level was significantly elevated in the MAFLD group than in the healthy control group (SMD = 0.97 pg/mL, 95%CI: 0.77, 1.18). Conversely, there was no significant difference in the ANGPTL4 (SMD = 0.11 ng/mL, 95%CI: − 0.32, 0.54) and ANGPTL3 (SMD = − 0.95 ng/mL, 95%CI: − 4.38, 2.48) between the two groups. Subgroup analysis showed that: 1) the MAFLD group had significantly higher ANGPTL8 levels than the healthy control group in Asian and other races; 2) the ANGPTL8 levels in Body Mass Index (BMI) > 25 kg/m2 patients with MAFLD were higher than those in the healthy control group; 3) the higher ANGPTL8 levels were observed in moderate to severe MAFLD group than the healthy control group. Meta-regression demonstrated that BMI might effectively explain the high heterogeneity. No significant publication bias existed (P > 0.05). The certainty of evidence was assessed as very low by the GRADE system. Conclusions The ANGPTLs may be related to MAFLD. The increased ANGPTL8 level may be positively correlated with different situations of MAFLD, which may act as a potential indicator to monitor the development trends.

Lumbar Roll Usage While Sitting Reduces the Forward Head Posture in Healthy Individuals: A Systematic Review with Meta-Analysis

This systematic review and meta-analysis investigated whether the use of a lumbar roll reduced forward head posture (FHP) while sitting among individuals with or without musculoskeletal disorders. EMBASE, MEDLINE, and the Cochrane Library were systematically searched from their inception to August 2020. The quality of evidence for variables used in the meta-analysis was determined using the GRADE system. Five studies satisfied the criteria for data analysis. All studies included individuals without any spinal symptoms. Data from five studies on neck angle showed a statistically significant (p = 0.02) overall effect (standardized mean difference (SMD) = 0.77), indicating a lesser neck flexion angle while sitting with a lumbar roll than without it. Data from two studies on head angle showed a statistically significant (p = 0.04) overall effect (SMD = 0.47), indicating a lesser head extension angle while sitting with a lumbar roll than without it. In each meta-analysis, the quality of evidence was very low in the GRADE system. The use of a lumbar roll while sitting reduced FHP among individuals without spinal symptoms.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

BackgroundEnhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.MethodsWe included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.ResultsWe identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.ConclusionsWe identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.