North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management.

Hidradenitis suppurativa is a severe and debilitating dermatologic disease. Clinical management is challenging and consists of both medical and surgical approaches, which must often be combined for best outcomes. Therapeutic approaches have evolved rapidly in the last decade and include the use of topical therapies, systemic antibiotics, hormonal therapies, and a wide range of immunomodulating medications. An evidence-based guideline is presented to support health care practitioners as they select optimal medical management strategies and is reviewed in this second part of the management guidelines. A therapeutic algorithm informed by the evidence available at the time of the review is provided.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

Colorectal cancer screening in rural and poor-resourced communities.

To test the efficacy of a community-based intervention, Empowering Communities for Life (EC4L), designed to increase colorectal cancer (CRC) screening through fecal occult blood test (FOBT) in rural underserved communities in a randomized controlled trial. Participants were randomized into 3 groups (2 interventions and 1 control). Interventions were delivered by community lay health workers or by academic health professionals. The main outcome of interest was return rate of FOBT screening kit within 60 days. Participants included 330 screening-eligible adults. The overall return rate of FOBT kits within 60 days was 32%. The professional group (Arm 2) had the highest proportion of returned FOBTs within 60 days at 42% (n = 46/110), a significantly higher return rate than the lay group (Arm 1) [28%(n = 29/103);P = 0.0422] or control group (Arm 3) [25%(n = 29/117);P = 0.0099]. Thus, one arm (Arm 2) of our intervention produced significantly higher CRC screening through FOBT. Community-based participation partnered with academic health professionals enhanced CRC screening among rural and poor-resourced communities.

Cardiovascular Effects of the MEK Inhibitor, Trametinib: A Case Report, Literature Review, and Consideration of Mechanism.

The MEK inhibitor trametinib was approved in 2013 for the treatment of unresectable or metastatic melanoma with a BRAF V600E mutation, the most common pathogenic mutation in melanoma. Trametinib blocks activation of ERK1/2, inhibiting cell proliferation in melanoma. ERK1/2 also protects against multiple types of cardiac insult in mouse models. Trametinib improves survival in melanoma patients, but evidence of unanticipated cardiotoxicity is emerging. Here we describe the case of a patient with metastatic melanoma who developed acute systolic heart failure after trametinib treatment and present the results of the literature review prompted by this case. A patient with no cardiac history presented with a 6.5-mm skin lesion and was found to have metastatic BRAF V600E melanoma. Combination treatment with trametinib and the BRAF inhibitor, dabrafenib, was initiated. The patient's pre-treatment ejection fraction was 55-60%. His EF declined after 13 days and that was 40% 1 month after treatment. Two months after initiating trametinib, he developed dyspnea and fatigue. We conducted a chart review in the electronic medical record. We conducted a PubMed search using trametinib/adverse effects AND ("heart failure" OR "left ventricular dysfunction" OR hypertension OR cardiotoxicity OR mortality). We also queried the FDA Adverse Events Reporting System for reports of cardiomyopathy, ejection fraction decrease, and left ventricular dysfunction associated with trametinib between January 1, 2013, and July 20, 2017. The literature search retrieved 19 articles, including clinical trials and case reports. Early clinical experience with the MEK inhibitor trametinib suggests that its clinical efficacy may be compromised by cardiotoxicity. Further studies in humans and animals are required to determine the extent of this adverse effect, as well as its underlying mechanisms.

Functional Outcomes Following Radical Cystectomy in Women with Bladder Cancer: A Systematic Review.

CONTEXT: Gender-specific functional and health-related quality of life (HRQOL) outcomes following radical cystectomy (RC) for bladder cancer (BCa) remain unclear, with many studies excluding women from the study population. OBJECTIVE: To better characterize female-specific functional outcomes following RC and urinary diversion for BCa. EVIDENCE ACQUISITION: We performed a critical review of PubMed/Medline and Embase in August 2015 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Outcomes of interest included urinary function (for orthotopic neobladder), sexual function, bowel function, and quality of life. Excluded were nonbladder malignancies, RCs performed for neurogenic bladder dysfunction, and patients with exposure to radiation therapy prior to surgery. Forty-five publications were selected for inclusion in this analysis. EVIDENCE SYNTHESIS: Included reports addressed urinary function (34 studies), sexual function (11 studies), and HRQOL (9 studies). All studies had a high risk of bias and ranged significantly in sample size, inclusion criteria, and follow-up time, precluding meaningful meta-analysis. Daytime incontinence approximated 20%, nighttime incontinence 20%, and hypercontinence 10-20%. Sexual function appeared to be better among those patients undergoing genitalia-sparing RC, but generally poor outcomes were noted among those undergoing routine RC. Only 40% of studies assessed sexual function using standardized instruments. HRQOL differences between diversion types appeared to be minimal, whereas comparisons with the general population revealed significant differences in emotional problems, role functioning, fatigue, and appetite. CONCLUSIONS: Functional outcomes among women undergoing RC for BCa are poorly studied with limitations regarding use of validated questionnaires, heterogeneous patient populations, and small sample sizes. Collaborative efforts will be needed to better define functional outcomes among this poorly studied patient population. PATIENT SUMMARY: We reviewed functional outcomes following cystectomy among women with bladder cancer. We found that urinary, sexual, and bowel function and quality of life are poorly studied among women, with function ranging significantly across studies.

Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis.

OBJECTIVE: To evaluate how varicocele repair (VR) impacts pregnancy (PRs) and live birth rates in infertile couples undergoing assisted reproduction wherein the male partner has oligospermia or azoospermia and a history of varicocele. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Azoospermic and oligospermic males with varicoceles and in couples undergoing assisted reproductive technology (ART) with IUI, IVF, or testicular sperm extraction (TESE) with IVF and intracytoplasmic sperm injection (ICSI). INTERVENTION(S): Measurement of PRs, live birth, and sperm extraction rates. MAIN OUTCOME MEASURE(S): Odds ratios for the impact of VR on PRs, live birth, and sperm extraction rates for couples undergoing ART. RESULT(S): Seven articles involving a total of 1,241 patients were included. Meta-analysis showed that VR improved live birth rates for the oligospermic (odds ratio [OR] = 1.699) and combined oligospermic/azoospermic groups (OR = 1.761). Pregnancy rates were higher in the azoospermic group (OR = 2.336) and combined oligospermic/azoospermic groups (OR = 1.760). Live birth rates were higher for patients undergoing IUI after VR (OR = 8.360). Sperm retrieval rates were higher in persistently azoospermic men after VR (OR = 2.509). CONCLUSION(S): Oligospermic and azoospermic patients with clinical varicocele who undergo VR experience improved live birth rates and PRs with IVF or IVF/ICSI. For persistently azoospermic men after VR requiring TESE for IVF/ICSI, VR improves sperm retrieval rates. Therefore, VR should be considered to have substantial benefits for couples with a clinical varicocele even if oligospermia or azoospermia persists after repair and ART is required.

ClinicalAccess: a clinical decision support tool.

ClinicalAccess is a new clinical decision support tool that uses a question-and-answer format to mirror clinical decision-making strategies. The unique format of ClinicalAccess delivers concise, authoritative answers to more than 120,000 clinical questions. This column presents a review of the product, a sample search, and a comparison with other point-of-care search engines.

Geriatric assessment in surgical oncology: a systematic review.

BACKGROUND: The comprehensive geriatric assessment (CGA) has developed as an important prognostic tool to risk stratify older adults and has recently been applied to the surgical field. In this systematic review, we examined the utility of CGA components as predictors of adverse outcomes among geriatric patients undergoing major oncologic surgery. MATERIALS AND METHODS: MEDLINE, Embase, and the Cochrane Library were searched for prospective studies examining the association of components of the CGA with specific outcomes among geriatric patients undergoing elective oncologic surgery. Outcome parameters included 30-d postoperative complications (POC), mortality, and discharge to a nonhome institution. RESULTS: The initial search identified 178 potentially relevant articles, with six studies meeting inclusion criteria. Deficiencies in instrumental activities of daily living, activities of daily living, fatigue, cognition, frailty, and cognitive impairment were associated with increased POC. No CGA predictors were identified for postoperative mortality whereas frailty, deficiencies in instrumental activities of daily living, and depression predicted discharge to a nonhome institution. CONCLUSIONS: Across a variety of surgical oncologic populations and cancer types, components of the CGA appear to be predictive of POC and discharge to a nonhome institution. These results argue for inclusion of focused geriatric assessments as part of routine preoperative care in the geriatric surgical oncology population.

Non-publication of large randomized clinical trials: cross sectional analysis.

OBJECTIVE: To estimate the frequency with which results of large randomized clinical trials registered with ClinicalTrials.gov are not available to the public. DESIGN: Cross sectional analysis SETTING: Trials with at least 500 participants that were prospectively registered with ClinicalTrials.gov and completed prior to January 2009. DATA SOURCES: PubMed, Google Scholar, and Embase were searched to identify published manuscripts containing trial results. The final literature search occurred in November 2012. Registry entries for unpublished trials were reviewed to determine whether results for these studies were available in the ClinicalTrials.gov results database. MAIN OUTCOME MEASURES: The frequency of non-publication of trial results and, among unpublished studies, the frequency with which results are unavailable in the ClinicalTrials.gov database. RESULTS: Of 585 registered trials, 171 (29%) remained unpublished. These 171 unpublished trials had an estimated total enrollment of 299,763 study participants. The median time between study completion and the final literature search was 60 months for unpublished trials. Non-publication was more common among trials that received industry funding (150/468, 32%) than those that did not (21/117, 18%), P=0.003. Of the 171 unpublished trials, 133 (78%) had no results available in ClinicalTrials.gov. CONCLUSIONS: Among this group of large clinical trials, non-publication of results was common and the availability of results in the ClinicalTrials.gov database was limited. A substantial number of study participants were exposed to the risks of trial participation without the societal benefits that accompany the dissemination of trial results.

Clinical inquiry: what medications are best for diabetic neuropathic pain?

Tricyclic antidepressants, duloxetine, pregabalin, oxycodone, and tramadol are all effective for the symptomatic treatment of painful diabetic neuropathy.

Clinical inquiry: what risk factors contribute to C difficile diarrhea?

Certain antibiotics and using 3 or more antibiotics at one time are associated with Clostridium difficile-associated diarrhea. Hospital risk factors include proximity to other patients with C difficile and longer length of stay. Patient risk factors include advanced age and comorbid conditions. Acid suppression medication is also a risk factor for CDAD.

Clinical inquiries: What blood tests help diagnose celiac disease?

Histological confirmation of infiltrative lesions via small bowel biopsy is the gold standard for diagnosing celiac disease. Four serum antibody assays may serve as a first-step diagnostic tool to identify biopsy candidates: immunoglobulin A tissue transglutaminase (IgA tTG), IgA endomysial antibody (IgA EMA), IgA antigliadin antibody (IgA AGA), and IgG antigliadin antibody (IgG AGA). IgA tTG and IgA EMA offer the best diagnostic accuracy. Patients with selective IgA deficiency may have falsely negative IgA assays (strength of recommendation [SOR]: B, based on a systematic review, multiple small cross-sectional studies, and expert opinion).

Clinical inquiries. Which vaccinations are indicated after splenectomy?

Immunization against encapsulated bacterial pathogens decreases the incidence of post-splenectomy sepsis. Pneumococcal, meningococcal, and Haemophilus influenzae (Hib) vaccinations are indicated for patients after splenectomy. These immunizations should be given at least 14 days before a scheduled splenectomy, or given after the fourteenth postoperative day (strength of recommendation [SOR]: A, based on systematic review of RCTs for the pneumococcal vaccine; SOR: B, based on systematic review of clinical trials for meningococcal and Hib vaccines).

A study of personal digital assistants to enhance undergraduate clinical nursing education.

This study reports on personal digital assistants (PDAs) as a means to prepare nurse professionals who value and seek current information. An interdisciplinary team of nursing and library faculty, information technology and bookstore staff, students, and educational consultants developed this project. A pre-post and comparative group design of second-degree students in the accelerated and traditional baccalaureate nursing degree (BSN) options was used to examine students' information-seeking behaviors, and the effectiveness and cost of innovation strategies associated with incorporation of PDAs into students' clinical practice. Results of this study support PDAs as an effective student learning resource, especially for reference materials. The student group with PDAs had increasing numbers of questions associated with clinical situations and a greater recognition of the need to use current resources. Students made substantial use of their PDAs and health team members, while decreasing reliance on textbooks and clinical faculty. Students' use of and satisfaction with this technology is linked to access speed and readability. Providing faculty with PDAs is recommended to enhance their comfort with and incorporation of PDAs into clinical teaching.

Use of on-line evidence-based resources at the point of care.

BACKGROUND AND OBJECTIVES: The utility of on-line evidence-based summary databases for answering clinical questions at the point of care is not well understood. Our objectives were to determine if family physician faculty could answer their questions using on-line resources and the proportion of answers that influenced patient care. METHODS: This was a prospective study in which clinical faculty in an urban residency training office recorded their clinical questions and their search results. RESULTS: Faculty asked 92 questions. Therapy, prognosis, and epidemiology questions were the most common types of inquiries. Fifty-four percent of the questions were fully or partially answered by use of an on-line resource; obtaining an answer required 5-10 minutes of searching. Physicians reported that 62% of the obtained answers modified their opinion, influenced the care of the current patient 56% of the time, and would affect the care of future patients 70% of the time. Slow Internet connection and interruptions were the most frequent barriers reported. DISCUSSION: Practicing physicians inexperienced in the use of on-line evidence-based resources answered a proportion of their clinical questions that was comparable to reports of more-experienced searchers; however, the time required to find answers limits the practical use of these databases during patient care time. On-line summary databases such as those used in this study show promise in providing answers that influence care during the patient's visit. With faster Internet connection (or handheld devices) and improved navigability, such resources have the potential to optimize health care in the primary care setting.

Extending the hand of knowledge: promoting mobile technologies.

The widespread use of handheld computers and other mobile devices in the healthcare environment and their potential for providing access to information has prompted health sciences librarians everywhere to learn more about this technology. Early in 2001, the Health Sciences Library (HSL) at the University of North Carolina at Chapel Hill began exploring ways to support mobile computing. This paper describes the four basic approaches taken by the librarians that helped establish the HSL as a leader in the area of mobile technologies.