ABSTRACT
ABSTRACT: Musculoskeletal (MSK) conditions are often managed in primary care settings. To facilitate research and health care quality, practice-based research networks (PBRNs) offer sustained collaborations between clinicians and researchers. A scoping review was conducted to describe characteristics of PBRNs used for MSK research and MSK research conducted through PBRNs. PBRNs were identified from 1) MSK-studies identified In OVID Medline, CINAHL, and Embase databases from inception to 05 February 2023 and in ClinicalTrials.gov; and 2) from PBRN registries and websites. Among active MSK-focused PBRNs (i.e., currently recruiting and conducting research), an assessment of PBRN research good practices was performed. After screening 3025 records, 85 studies from 46 unique PBRNs met our eligibility criteria. Common conditions studied were low back pain (28%), MSK conditions not otherwise specified (25%), and osteoarthritis (19%). 32 PBRNs (70%) were deemed to be active. Among active MSK-focused PBRNs, best practice data management information was retrievable for most (53%). Due to the scarcity of publicly available information, a large proportion of PBRN research good practice items was not assessable. PBRNs have provided an avenue to assess clinical practice and patient outcomes related to MSK conditions. Further work to increase the transparency of MSK PBRN research practices is warranted.
ABSTRACT
Along with the increasing global burden of diabetes, diabetic foot infections (DFI) and diabetic foot osteomyelitis (DFO) remain major challenges for patients and society. Despite progress in the development of prominent international guidelines, the optimal medical treatment for DFI and DFO remains unclear as to whether local antibiotics, that is, topical agents and local delivery systems, should be used alone or concomitant to conventional systemic antibiotics. To better inform clinicians in this evolving field, we performed a narrative review and summarized key relevant observational studies and clinical trials of non-prophylactic local antibiotics for the treatment of DFI and DFO, both alone and in combination with systemic antibiotics. We searched PubMed for studies published between January 2000 and October 2022, identified 388 potentially eligible records, and included 19 studies. Our findings highlight that evidence for adding local antibiotic delivery systems to standard DFO treatment remains limited. Furthermore, we found that so far, local antibiotic interventions have mainly targeted forefoot DFO, although there is marked variation in the design of the included studies. Suggestive evidence emerging from observational studies underscores that the addition of local agents to conventional systemic antibiotics might help to shorten the clinical healing time and overall recovery rates in infected diabetic foot ulcers, although the effectiveness of local antibiotics as a standalone approach remains overlooked. In conclusion, despite the heterogeneous body of evidence, the possibility that the addition of local antibiotics to conventional systemic treatment may improve outcomes in DFI and DFO cannot be ruled out. Antibiotic stewardship principles call for further research to elucidate the potential benefits of local antibiotics alone and in combination with conventional systemic antibiotics for the treatment of DFI and DFO.
ABSTRACT
Dear editor, We read with interest the article entitled “The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health care” by Ordunez and colleagues, published on March 28th, 2022 (1). This article describes a recently developed app to assess cardiovascular disease (CVD) risk, as well as its use, potential functionality, and validation process. Despite the central role of the HEARTS initiative in the Americas and in the vulnerable region of Latin America and the Caribbean (LAC), we believe that the interpretation of the findings of this study requires some caution. There are some methodological issues in this manuscript that could compromise the strong conclusion that “the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.” First, the risk prediction models that inform this app are derived from 85 cohorts from high-income countries in the Emerging Risk Factors Collaboration study (2). Of these, we were only able to identify the Puerto Rico Heart Health Program study as directly representative of the LAC region. Therefore, the lack of representativeness of the models for risk-prediction should be made more explicit. At the same time, the important role of the STEPwise approach to surveillance to obtain population-level indicators and trends, as well as calibration of the risk-prediction models should be both considered as potential solutions to this issue. Second, the authors state that “the app is intended to be used in clinical practice, especially at the primary health care level” although it can also “be used by anyone in the general population.” If the use of the app is available to the general public, this could systematically exclude underrepresented groups by creating differential engagement and generating digital inequity (3). Hence, the “ideal” target population of the app in low- and middle-income countries should be specified. Third, the language of the article should reflect the uncertainty regarding the long-term success of this digital health application in the region, which will likely depend on how it is implemented and maintained over time, and the promptness of the initiation of effective pharmacological treatment after the obtention of a risk score. Several barriers to the implementation of CVD risk calculators in primary care have been described, including time constraints, lack of electronic health records integration, and patient fears (4). Low-resource contexts potentially require tailoring of the app to address some of these barriers and ensure sustainability. The burden of CVD in LAC, estimated at 3 497.14 disabilityadjusted life years per 100 000 (range, 3 226.2 – 3 790.1), appears to be highly influenced by the years lived with disability due to ischemic heart disease (5) and by the increasing impact of high systolic blood-pressure (≥110-115 mmHg according to the Global Burden of Disease definition) as the leading mortality risk factor in the region. This public health scenario presents both a tremendous challenge and an opportunity for improvement. The HEARTS app is a promising driver of change. However, its validity should be evaluated in view of some methodological caveats and its implementation capacity should stress the letter “A” of its acronym to advocate for equitable “access to essential medicines and technology” in places where the availability and affordability of generic drugs is still scarce. To read the complete letter, please download the manuscript using the link on the left.
