Clinical practice guidelines on the management of status epilepticus in adults: A systematic review.

OBJECTIVE: Status epilepticus (SE) is the second most common neurological emergency in adults. Despite improvements in the management of acute neurological conditions over the last decade, mortality is still durably high. Because a gap has emerged between SE management based on clinical practice guidelines (CPGs) and actual clinical practice, we conducted a systematic review of CPGs, assessing their quality, outlining commonalities and discrepancies in recommendations, and highlighting research gaps. METHODS: We searched the PubMed and EMBASE databases and other gray literature sources (nine among guideline registries, evidence-based medicine databases, point-of-care tools; seven websites of governmental organizations and international neurologic societies) in December 2021 (updated in November 2023). The units of analysis were CPGs that included recommendations on the diagnostic and/or therapeutic management of SE in adults. The quality of the CPGs was assessed using the AGREE II tool. RESULTS: Fifteen CPGs were included. The "Applicability" domain was assigned the lowest median score of 10%. The domains "Stakeholder Involvement", "Rigor of Development," and "Editorial Independence" were as well generally underrated. Recommendations on general and diagnostic management and on organizational interventions were fragmented and scattered. Recommendations on pre-hospital and hospital treatment of early-onset and refractory SE were broadly agreed, whereas there was less agreement on the treatment model and medications for established SE and super-refractory SE. SIGNIFICANCE: The CPGs for the management of SE developed in recent years are flawed by several methodological issues and discrepancies in the coverage of important topics. The gap between CPG-based management of SE and actual clinical practice may be due in part to the inherent limitations of the CPGs produced so far.

Medico-legal assessment of personal damage in older people: report from a multidisciplinary consensus conference.

Ageing of the global population represents a challenge for national healthcare systems and healthcare professionals, including medico-legal experts, who assess personal damage in an increasing number of older people. Personal damage evaluation in older people is complex, and the scarcity of evidence is hindering the development of formal guidelines on the subject. The main objectives of the first multidisciplinary Consensus Conference on Medico-Legal Assessment of Personal Damage in Older People were to increase knowledge on the subject and establish standard procedures in this field. The conference, organized according to the guidelines issued by the Italian National Institute of Health (ISS), was held in Bologna (Italy) on June 8, 2019 with the support of national scientific societies, professional organizations, and stakeholders. The Scientific Technical Committee prepared 16 questions on 4 thematic areas: (1) differences in injury outcomes in older people compared to younger people and their relevance in personal damage assessment; (2) pre-existing status reconstruction and evaluation; (3) medico-legal examination procedures; (4) multidimensional assessment and scales. The Scientific Secretariat reviewed relevant literature and documents, rated their quality, and summarized evidence. During conference plenary public sessions, 4 pairs of experts reported on each thematic area. After the last session, a multidisciplinary Jury Panel (15 members) drafted the consensus statements. The present report describes Conference methods and results, including a summary of evidence supporting each statement, and areas requiring further investigation. The methodological recommendations issued during the Conference may be useful in several contexts of damage assessment, or to other medico-legal evaluation fields.

[Temporary percutaneous ventricular assist devices for cardiogenic shock and high-risk percutaneous coronary intervention: a systematic literature review]. / Sistemi percutanei di assistenza ventricolare temporanea per lo shock cardiogeno e la rivascolarizzazione coronarica percutanea ad alto rischio: revisione sistematica della letteratura.

BACKGROUND: Percutaneous ventricular assist devices (pVADs) are frequently used for the treatment of patients with cardiogenic shock (CS) due to acute myocardial infarction (AMI) and as a support in percutaneous coronary intervention (PCI) for high-risk patients. CS is a clinical condition characterized by inadequate tissue perfusion due to cardiac dysfunction and for 80% of cases it is caused by AMI with left ventricular insufficiency. CS is responsible for about 50% of deaths in patients with myocardial infarction. Usually, PCIs do not require hemodynamic support, which could be however necessary in patients undergoing high-risk PCI. Presently, available pVADs in Europe are Impella 2.5, Impella CP, HeartMate PHP, TandemHeart, PulseCath iVAC2L. The aim of this review is to evaluate the efficacy and safety of pVADs in patients with refractory CS complicating AMI or undergoing high-risk PCI. METHODS: We systematically searched for randomized controlled trials (RCTs) and controlled observational studies in PubMed, Embase and PubMed CENTRAL databases until September 2018. We included studies comparing pVADs with intra-aortic balloon pumps (IABP) or medical therapy in patients with CS complicating AMI or undergoing high-risk PCI. Researchers independently assessed records' eligibility, inclusion and methodological quality of included studies. If possible, data of included studies was combined in a meta-analysis. Risk ratio (RR) and 95% confidence interval (CI) were calculated using a random effects model. RESULTS: Overall, 8 studies were included. Five studies (3 RCTs and 2 observational studies) evaluated pVADs in patients with SC complicating AMI. Meta-analyses showed that 30-day mortality did not differ between patients treated with pVADs and the control group (RR 1.05, 95% CI 0.84-1.31). However, risk of major bleeding was 2 times higher in patients treated with pVADs compared to controls. Three studies evaluated pVADs in patients undergoing high-risk PCI. Due to the lack of data, it was not possible to combine study results in a meta-analysis. One RCT reported no difference in 30- and 90-day mortality between patients randomized to Impella or IABP. Two non-randomized controlled studies reported no difference in terms of in-hospital all-cause mortality between the two groups. CONCLUSIONS: Our meta-analysis suggests similar results in terms of efficacy and safety between pVADs and control (IABP and medical therapy) for the treatment of patients with CS complicating AMI or undergoing high-risk PCI.

Comparison of cryoballoon and radiofrequency ablation techniques for atrial fibrillation: a meta-analysis.

AIMS: To perform an updated meta-analysis to assess efficacy, safety and technical performance of pulmonary vein isolation using cryoballoon or radiofrequency catheter ablation in patients with paroxysmal or persistent atrial fibrillation. METHODS: In June 2017, databases and websites were systematically searched for systematic reviews, randomized controlled trials and observational studies reporting data on efficacy, safety and technical performance outcomes at follow-up at least 12 months. Researchers independently assessed records' eligibility, inclusion and methodological quality of included studies. RESULTS: Six randomized controlled trials and 25 observational studies - 11 853 patients were included. Studies on paroxysmal atrial fibrillation were 29 and included 11 635 patients. Meta-analysis results showed no difference between cryoballoon and radiofrequency in terms of recurrent atrial fibrillation [risk ratio 1.04, 95% confidence interval (CI) 0.98-1.10] or atrial tachyarrhythmias (risk ratio 1.04, 95% CI 1-1.08) and fluoroscopy time (mean difference -1.92 min, 95% CI -4.89 to 1.05). Cryoballoon ablation was associated with fewer reablations (risk ratio 0.79, 95% CI 0.64-0.98), lower incidence of pericardial effusion (risk ratio 0.52, 95% CI 0.31-0.89) and cardiac tamponade (risk ratio 0.33, 95% CI 0.18-0.62) and shorter total procedural time (mean difference -23.48 min, 95% CI -37.97; -9.02) but with higher incidence of phrenic nerve palsy (risk ratio 5.43, 95% CI 2.67-11.04). Prespecified subgroup analysis confirmed overall results as for freedom from atrial fibrillation and atrial tachyarrhythmias. Only two observational studies included patients with persistent atrial fibrillation, thus hindering any conclusion in this population. CONCLUSION: In patients with paroxysmal atrial fibrillation, cryoballoon and radiofrequency ablation produce similar results in terms of freedom from recurrent atrial fibrillation or atrial tachyarrhythmias but with a different safety profile, being cryoballoon ablation less associated with cardiac complications but more likely to cause phrenic nerve palsy.

Recommendations for the management of biofilm: a consensus document.

The potential impact of biofilm on healing in acute and chronic wounds is one of the most controversial current issues in wound care. A significant amount of laboratory-based research has been carried out on this topic, however, in 2013 the European Wound Management Association (EWMA) pointed out the lack of guidance for managing biofilms in clinical practice and solicited the need for guidelines and further clinical research. In response to this challenge, the Italian Nursing Wound Healing Society (AISLeC) initiated a project which aimed to achieve consensus among a multidisciplinary and multiprofessional international panel of experts to identify what could be considered part of 'good clinical practice' with respect to the recognition and management of biofilms in acute and chronic wounds. The group followed a systematic approach, developed by the GRADE working group, to define relevant questions and clinical recommendations raised in clinical practice. An independent librarian retrieved and screened approximately 2000 pertinent published papers to produce tables of levels of evidence. After a smaller focus group had a multistep structured discussion, and a formal voting process had been completed, ten therapeutic interventions were identified as being strongly recommendable for clinical practice, while another four recommendations were graded as being 'weak'. The panel subsequently formulated a preliminary statement (although with a weak grade of agreement): 'provided that other causes that prevent optimal wound healing have been ruled out, chronic wounds are chronically infected'. All members of the panel agreed that there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence. In the meantime it was agreed that expert-based guidelines were needed to be developed for the recognition and management of biofilms in wounds and for the best design of future clinical trials. This is a fundamental and urgent task for both laboratory-based scientists and clinicians.

Informative value of clinical research on multislice computed tomography in the diagnosis of coronary artery disease: A systematic review.

UNLABELLED: Multislice Spiral Computed Tomography (MSCT) is an emerging non-invasive diagnostic modality to detect coronary artery disease, which may alter diagnostic pathways and change the current clinical role of conventional coronary angiography. AIMS: To retrieve and critically assess information from the available literature on MSCT (>/=16-slice) concerning its diagnostic accuracy, safety, applicability, clinical impact and cost-effectiveness. METHODS AND RESULTS: Articles published between January 2002 and March 2007 were identified through searches of the Cochrane Library, MEDLINE, and other websites of manufacturers, cardiac professional societies, guidelines and abstracts from conference meetings. We identified 1768 potentially relevant articles: 262 out of these were considered eligible for full evaluation and 150 were selected (57 assessed diagnostic accuracy, 130 applicability, 103 safety, 1 clinical impact and none cost-effectiveness). The pre test probability of coronary artery disease was 56.7% (95% Confidence Interval: 55.1%-58.3%). A positive MSCT finding (pooled LR+: 5.4 (4.4-6.7)) increased the probability of CAD to 87.7% (84.3%-90.3%), whereas a negative MSCT result (pooled LR-: 0.09 (0.07-0.12)) reduced the probability of CAD to 10.7% (7.9%-14.4%). CONCLUSIONS: MSCT is a promising technology for the assessment of coronary artery stenosis. However, the available literature is of limited value in providing guidance to support the development of policies for its appropriate utilization in clinical practice.