Identification of Priority Health Topics at the Primary Care Level in the Dominican Republic / Identificación de temáticas prioritarias de salud en el primer nivel de atención en República Dominicana

Introduction: The Sustainable Development Goals (SDGs), especially SDG 3, aim to ensure healthy lives and promote well-being through universal health coverage, which includes equitable access to essential health services and medicines. The Primary Health Care (PHC) strategy, endorsed since 1978 and reaffirmed in the Astana Declaration, is pivotal for achieving these goals by strengthening the first level of care. However, in the Dominican Republic, the first level of care remains inadequate due to constraints in human resources, supplies, and technology, impacting the health system's effectiveness and leading to higher costs and poorer health outcomes. Coordinated efforts and evidence-based policies are crucial for improving primary care and addressing the country's epidemiological needs to progress towards universal health coverage. Objective: To identify priority themes for evidence-based decision-making for primary health care professionals in the Dominican Republic. Methods: An electronic survey was conducted with a stratified sampling and comparison with epidemiological data. A total of 475 individuals providing services at the first level of care within the National Health Service (SNS) of the Dominican Republic participated during the period from October 2022 to July 2023. Results: High-demand services included pharmaceutical care (52.2%), general medicine consultations (56.0%), and vaccination (37.3%). The most challenging conditions to diagnose were seizures and loss of consciousness in children (38.1%), seizures and loss of consciousness in adults (32.2%), ear problems (29.9%), vision changes (25.7%), and chest pain (22.4%). The diagnoses with the greatest difficulty in formulating a treatment plan and/or intervention were airway obstruction due to a foreign body (27.4%), threatened abortion/abortion (19.8%), organophosphate poisoning (19.4%), acute myocardial infarction (18.8%), and bacterial meningitis (16.7%). Conclusions: To enhance the primary health care system in the Dominican Republic and address priority needs, it is essential to expand the service portfolio, strengthen the competencies of health professionals, and provide technological tools and support for evidence-based decision-making.

Introducción. Los Objetivos de Desarrollo Sostenible (ODS), especialmente el ODS 3, buscan garantizar una vida sana y promover el bienestar a través de la cobertura sanitaria universal, que incluye acceso equitativo a servicios de salud esenciales y medicamentos. La estrategia de Atención Primaria de Salud (APS), promovida desde 1978 y reafirmada en la Declaración de Astaná, se considera fundamental para lograr estos objetivos al fortalecer el primer nivel de atención. Sin embargo, en República Dominicana, el primer nivel de atención sigue siendo insuficiente debido a limitaciones en recursos humanos, insumos y tecnología, lo que afecta la eficacia del sistema de salud y resulta en mayores costos y peores resultados de salud. Es crucial coordinar esfuerzos y políticas basadas en evidencia para mejorar la atención primaria y abordar las necesidades epidemiológicas del país, y así avanzar hacia la cobertura sanitaria universal. Objetivo. Identificar temáticas prioritarias para la toma de decisiones basadas en evidencia para los profesionales de salud del primer nivel de atención en la República Dominicana. Métodos. Se realizó una encuesta electrónica con un muestreo estratificado y comparación con datos epidemiológicos. Participaron 475 personas que prestaron servicio en el primer nivel de atención en el Servicio Nacional de Salud (SNS) de la República Dominicana, durante el periodo octubre 2022- julio del 2023. Resultados: Los servicios de alta demanda fueron: atención farmacéutica (52.2%), consulta de medicina general (56.0%) y vacunación (37.3%). L,as situaciones con una mayor dificultad para ser diagnosticadas fueron: convulsiones y pérdida de conocimiento en niños (38.1%),  convulsiones y pérdida de conocimiento en adultos (32.2%), problemas del oído (29.9%), cambios en la visión (25.7%) y dolor en el pecho (22.4%). Los diagnósticos con mayor dificultad a la hora de elaborar un plan de tratamiento y/o intervención fueron: obstrucción de vías respiratorias por cuerpo extraño (27.4%), amenaza de aborto/aborto (19.8%), intoxicación por órganos fosforados (19.4%), infarto agudo del miocardio (18.8%) y meningitis bacteriana (16.7%).  Conclusiones: Para fortalecer el primer nivel de atención en salud en la República Dominicana y dar respuesta a las necesidades prioritarias es necesario: ampliar la cartera de servicios, fortalecer las competencias de los recursos humanos en salud y proveer de herramientas tanto de tecnología sanitaria como de toma de decisiones basadas en evidencia. 

Applying Implementation Science to Advance Electronic Health Record-Driven Learning Health Systems: Case Studies, Challenges, and Recommendations.

With the widespread implementation of electronic health records (EHRs), there has been significant progress in developing learning health systems (LHSs) aimed at improving health and health care delivery through rapid and continuous knowledge generation and translation. To support LHSs in achieving these goals, implementation science (IS) and its frameworks are increasingly being leveraged to ensure that LHSs are feasible, rapid, iterative, reliable, reproducible, equitable, and sustainable. However, 6 key challenges limit the application of IS to EHR-driven LHSs: barriers to team science, limited IS experience, data and technology limitations, time and resource constraints, the appropriateness of certain IS approaches, and equity considerations. Using 3 case studies from diverse health settings and 1 IS framework, we illustrate these challenges faced by LHSs and offer solutions to overcome the bottlenecks in applying IS and utilizing EHRs, which often stymie LHS progress. We discuss the lessons learned and provide recommendations for future research and practice, including the need for more guidance on the practical application of IS methods and a renewed emphasis on generating and accessing inclusive data.

8. Herpes zoster and post herpetic neuralgia.

INTRODUCTION: Patients suffering from postherpetic neuralgia (PHN) report unilateral chronic pain in one or more dermatomes after an acute herpes zoster (HZ) infection. The incidence of acute HZ ranges between three and five patients per 1000 person-years. In one out of four patients, acute HZ-related pain will transition into PHN. PHN can be very disabling for patients and reduce quality of life. Additionally, the treatment of PHN is characterized by high failure rates. The aim of this review is to give an update on the previous practical guideline published in 2011 and revised in 2015 (published in 2019) and to provide an overview of current interventional treatment options for HZ infection and PHN. METHODS: The literature on the diagnosis and treatment of HZ and PHN was systematically reviewed and summarized. RESULTS: The most important treatment for acute HZ-related pain is antiviral therapy within 72 h of symptom onset. Additional symptomatic treatment options are analgesic drugs according to the WHO pain ladder, tricyclic antidepressants (eg, nortriptyline), and antiepileptic drugs (eg, gabapentin). If pain is not sufficiently reduced, interventional treatment such as an epidural injection with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion (DRG) are options. Treatment for PHN is preferably transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. CONCLUSIONS: Treatment of acute HZ-related pain especially PHN is challenging. Besides the conventional treatment for PHN, interventional management is considered a new treatment option. PRF of DRG seems to be the most promising interventional management.

A pragmatic approach to selecting a grading system for clinical practice recommendations in palliative care.

BACKGROUND: The limited palliative care evidence base is poorly amenable to existing grading schemes utilized in guidelines. Many recommendations are based on expert consensus or clinical practice standards, which are often considered 'low-quality' evidence. Reinforcing provider hesitancy in translating recommendations to practice has implications for patient care. AIM: To rationalize the selection of an appropriate grading system for rating evidence to support recommendations made in palliative care clinical practice guidelines. DESIGN: Review of the methodology sections of international palliative care guidelines published in English identified five grading systems comparison: Grading of Recommendations, Assessment, Development and Evaluations (GRADE); the Scottish Intercollegiate Guidelines Network (SIGN); Infectious Diseases Society of America-European Society for Medical Oncology (IDSA-ESMO); Confidence in the Evidence from Reviews of Qualitative research (CERQual) and the National Service Framework for Long Term Conditions (NSF-LTC). RESULTS: There is heterogeneity among grading systems used in published palliative care or terminal symptom management guidelines. GRADE has been increasingly adopted for its methodological rigour and inter-guideline consistency with other medical associations. CERQual has the potential to support recommendations informed by qualitative evidence, but its role in clinical guidelines is less defined. The IDSA-ESMO system has an intuitive typology with the ability to categorize tiers of lower-quality evidence. CONCLUSIONS: It is challenging to apply commonly used grading systems to the palliative care evidence base, which often lacks robust randomized controlled trials (RCTs). Adoption of IDSA-ESMO offers a feasible and practical alternative for lower-resourced guideline developers and palliative clinicians without a prerequisite for methodological expertise.

12. vascular pain Ischemic pain in the extremities and Raynaud's syndrome.

INTRODUCTION: Peripheral artery diseases (PAD) and Raynaud's syndrome are associated with substantial morbidity. PAD, through the restriction of blood flow to the extremities, may lead to critical limb ischemia with symptoms of pain at rest which may eventually progress to severe limb ischemia with gangrene. This serious and painful clinical condition requires extensive medical care, is limb-threatening and, in case of delayed or unsuccessful treatment, is associated with a high mortality rate. In Raynaud's syndrome, the blood supply to certain parts of the body, usually the fingers and toes and less frequently the nose or ears, is restricted because of vasculopathy of the smaller vessels at acral sites. Under certain circumstances, with cold as the most well-known provoking factor, blood flow restriction occurs, leading to demarcated color changes and symptoms such as pain, paresthesia, and numbness. In severe cases of Raynaud syndrome tissue ischemia may lead to necrosis and the need for amputation of the affected area. METHODS: In this narrative review, the literature on the diagnosis and interventional pain treatment of PAD and Raynaud's syndrome was updated and summarized. OBJECTIVES: This review focused on interventional pain treatment. In PAD, the effects of the intervention on limb salvage, ulcer healing, and ischemic pain were summarized. Additionally, results with respect to skin microcirculation and quality of life were reported if available. In Raynaud's syndrome, we focused on the effect of the intervention on peripheral blood flow metrics and pain intensity during attacks. RESULTS: In PAD, prevention and treatment of risk factors are important. Initially, conservative treatment and pharmacological therapy are preferred first-line therapies. However, when disease progression occurs, interventional management may be considered. The literature search yielded conflicting evidence for sympathectomy as a treatment for PAD. Spinal cord stimulation (SCS) as a treatment modality for advanced PAD had high-quality evidence for limb salvage in subgroups of patients but conflicting evidence for other outcome measures such as pain, wound healing, and quality of life. The literature search for interventional pain management in Raynaud's syndrome was limited to only one randomized controlled trial (RCT) studying the effect of thoracic sympathectomy. This study had several limitations and hence the level of evidence for this interventional treatment is very low. No RCTs studying SCS in patients with Raynaud's syndrome were found. CONCLUSIONS: In both PAD and Raynaud's syndrome, additional RCTs are needed to substantiate interventional (pain) management and bolster the evidence base for sympathectomy and SCS as treatment options.

Assessment of clinician agreement with and knowledge of evidence-based obesity treatment in the primary care setting.

Introduction: Effective, evidence-based obesity treatment is needed, which often involves use of anti-obesity medications (AOMs). Data on the breadth and quality of guideline-directed obesity treatment implementation in primary care remain limited. This study aimed to assess primary care clinicians' agreement with and knowledge of guideline-directed obesity treatment, as well as to assess the health status of persons with obesity and their use of AOMs. Methods: This multimethod study included a prospective survey of primary care clinicians, utilizing a questionnaire that measured agreement on a 5-point Likert scale and knowledge via multiple choice questions. A retrospective analysis was also performed of patient data collected between 30 June 2016 and 30 June 2020 from primary care clinics in the Midwest. Results: Data were analyzed from 27 clinician survey responders, finding agreement toward all measured areas, however less strong for chronic AOM use and resource allocation. The survey identified multiple gaps in knowledge. Researchers assessed 5656 baseline encounters and 2941 corresponding follow-up encounters. Analysis revealed ≥50% of the total patients experienced persistently uncontrolled obesity (mean body mass index of ≥40 kg/m2) and weight-related complications. Low rates (≤10%) of AOM use in clinically eligible patients were shown, with phentermine monotherapy being the most commonly used. Conclusions: Clinicians agree with guideline-directed obesity treatment. Persons with obesity who are poorly controlled identify an opportunity for patient care improvement.

'A challenge to my professional identity'- resisting the shift from over-management to self-management for back pain within an implementation trial: a qualitative study.

OBJECTIVE: The Enhanced Transtheoretical Model Intervention (ETMI) is based on behavioral models and focuses on guiding Chronic Low Back Pain (CLBP) patients to self-manage symptoms and engage in recreational physical activity. While there is promising evidence that ETMI benefits patients, it is unclear how challenging it might be to implement widely. This investigation focused on the perceptions of physiotherapists trained to deliver ETMI for CLBP. DESIGN: A Qualitative study comprised of semi-structured interviews (July to November 2023). Interviews were audio-recorded, transcribed, coded, and analyzed thematically by two independent researchers. SETTING: Data were obtained as part of a large implementation study evaluating the uptake and impact of ETMI amongst physiotherapists in a large public healthcare setting. PARTICIPANTS: 22 physiotherapists trained to deliver the ETMI approach and chose to use it with at least one patient. RESULTS: While physiotherapists acknowledged the evidence base behind ETMI and the clarity of the approach, they struggled to adapt it to routine delivery. Exploration of the reasons for this identified an overarching meta-theme, 'A challenge to my professional identity', and three main themes consisting of 1) interventions such as ETMI contradicted my training. 2) I am ambivalent/ do not accept evidence that contradicts my habitual practice, and 3) I am under-skilled in psychological and communication skills. CONCLUSION: This study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. The shift from over-management by experts seeking cures to supporting self-management was not palatable to physiotherapists. The challenge of embracing a new professional identity must be addressed to enable a successful implementation of the approach. CONTRIBUTION OF THE PAPER.

What is the probability that higher versus lower quality of evidence represents true effects estimates?

RATIONALE, AIMS, AND OBJECTIVES: The previous studies demonstrated that the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, a leading method for evaluating the certainty (quality) of scientific evidence (CoE), cannot reliably differentiate between various levels of CoE when the objective is to accurately assess the magnitude of the treatment effect. An estimated effect size is a function of multiple factors, including the true underlying treatment effect, biases, and other nonlinear factors that affect the estimate in different directions. We postulate that non-weighted, simple linear tallying can provide more accurate estimates of the probability of a true estimate of treatment effects as a function of CoE. METHODS: We reasoned that stable treatment effect estimates over time indicate truthfulness. We compared odds ratios (ORs) from meta-analyses (MAs) before and after updates, hypothesising that a ratio of odds ratios (ROR) equal to 1 will be more commonly observed in higher versus lower CoE. We used a subset of a previously analysed data set consisting of 82 Cochrane pairs of MAs in which CoE has not changed with the updated MA. If the linear model is valid, we would expect a decrease in the number of ROR = 1 cases as we move from high to moderate, low, and very low CoE. RESULTS: We found a linear relationship between the probability of a potentially 'true' estimate of treatment effects as a function of CoE (assuming a 10% ROR error margin) (R2 = 1; p = 0.001). The probability of potentially 'true' estimates decreases by 21% (95% CI: 18%-24%) for each drop in the rating of CoE. A linear relationship with a 5% ROR error margin was less clear, likely due to a smaller sample size. Still, higher CoE showed a significantly greater probability of 'true' effects (53%) compared to non-high (i.e., moderate, low, or very low) CoE (25%); p = 0.032. CONCLUSION: This study confirmed linear relationship between CoE and the probability of potentially 'true' estimates. We found that the probability of potentially "true" estimates decreases by about 20% for each drop in CoE (from about 80% for high to 55% for moderate to 35% to low and 15% to very low CoE).

[Evidence-based medicine and clinical ethics: toward shared decision making].

Evidence-based medicine (EBM) is "decision-making for better patient care that integrates current evidence, and clinical expertise with patients' preferences, values and circumstances." It is important to distinguish research evidence from EBM, which is comprehensive decision-making that takes into account the diversity and individuality of clinical situations while respecting evidence as a general theory. Clinical practice guidelines are "a document that evaluates the total body of evidence through systematic review and presents recommendations that are considered optimal, taking into account the balance of benefits and harms, in order to support decision-making on important health-related issues by healthcare users and providers," and is useful in the practice of EBM. Shared decision making (SDM), which has been attracting attention in recent years, is "a process in which the patient and the health care provider, through dialogue, decide on a treatment plan that is acceptable to the patient, based on the patient's own preferences and values, research evidence, and clinical expertise" and must be understood in relation to the above definition of EBM and from the perspective of clinical ethics.

Knowledge, attitude and practices of surgeons regarding venous thromboembolism prophylaxis in tertiary healthcare hospitals of the Rawalpindi Districts.

Objective: To assess doctors' knowledge, attitudes and practices regarding venous thromboembolism prophylaxis. METHODS: The cross-sectional study was conducted from April to September 2021 in three public-sector hospitals affiliated with the Rawalpindi Medical University: Holy Family Hospital, Benazir Bhutto Hospital and Rawalpindi District Headquarters Hospital, Rawalpindi, Pakistan, and comprised physicians of either gender who were actively involved in patient care. Data was collected using a predesigned questionnaire regarding venous thromboembolism. Data was analysed using SPSS 25. RESULTS: All the 220(100%) subjects approached responded positively to the study questionnaire. There were 144(65.45%) general surgeons, 50(22.72%) gynaecologists and 26(11.81%) orthopaedic surgeons. Overall, there were 26(11.81%) senior consultants, 65(29.54%) postgraduate residents and 129(58.63%) house officers. There were 150(68.2%) doctors who reported having witnessed deep-vein thrombosis in their patients, and 113(51.4%) had witnessed deaths related to pulmonary embolism. Among the methods employed for DVT diagnosis, the use of clinical criteria was the most common 136(36.1%), while venography was the least common technique used by 8(2.2%). While 210(95.5%) subjects expressed the desire for adopting an institute-wide regimen for venous thromboembolism prophylaxis, only 66(30%) were currently following such a regimen.

Implementation of WHO/PAHO Maternal Health Guidelines in the Dominican Republic / Implementación de recomendaciones de directrices de salud materna de la OMS/OPS en República Dominicana

Objective: To analyze the implementation of strong recommendations contained in the WHO and PAHO guidelines on maternal health in the Dominican Republic. Methods: A search was conducted for maternal health recommendations on the WHO's BIGG-REC platform. A total of 249 recommendations were identified: 215 strong recommendations in favor and 34 strong recommendations against, contained in 76 WHO guidelines formulated using the GRADE methodology from 2010 to 2022. These recommendations were classified into 6 domains: abortion, nutrition, hemorrhage, hypertension, infection, contraception, and public health. The characteristics and determinants that facilitate or hinder the implementation of these recommendations by the Dominican health system were analyzed. Results: 29 strong recommendations in favor were included, corresponding to the 6 domains. The recommendations with the highest level of implementation were those related to the management of obstetric hemorrhage and infection prevention. Recommendations related to abortion and public health programs had the lowest level of implementation. The main determinants for non-implementation are limitations in the legal or regulatory framework, disorganization of the service network, and social and cultural barriers. Discussion: Limitations persist in the Dominican Republic regarding the implementation of strong recommendations in maternal health from WHO guidelines. The results highlight the need to strengthen strategies for implementing recommendations in the areas of abortion care and public health interventions.

Objetivo. Analizar la implementación de las recomendaciones fuertes contenidas en las guías de la OMS y OPS sobre salud materna en la República Dominicana. Métodos: Se realizó una búsqueda de las recomendaciones de salud materna contenidas en la plataforma BIGG-REC de la Organización Mundial de la Salud (OMS). Se identificaron 249 recomendaciones: 215 recomendaciones fuertes a favor y 34 recomendaciones fuertes en contra, contenidas en 76 directrices de la OMS formuladas con metodología GRADE durante el periodo 2010-2022. Se clasificaron en 6 dominios: aborto, nutrición, hemorragia, hipertensión, infección, anticoncepción, salud pública. Se analizaron las características y los determinantes que facilitan o impiden la implementación de las recomendaciones por el sistema de salud dominicano. Resultados: Se incluyeron 29 recomendaciones fuertes a favor; correspondientes a los 6 dominios. Las recomendaciones con mayor nivel implementación fueron las relacionadas con la atención a la hemorragia obstétrica y prevención de infecciones.  Las relacionadas con Aborto y Programas de Salud Pública son las  de menor nivel de implementación. Los principales determinantes para la no implementación son limitaciones del marco legal o normativo, desorganización de la red de servicios y barreras sociales y culturales. Discusión: En República Dominicana persisten limitaciones para la implementación de recomendaciones fuertes del ámbito de la salud materna contenidas en   las directrices de la OMS. Los resultados muestran la necesidad de fortalecer estrategias para la implementación de recomendaciones en los ámbitos de atención al aborto e intervenciones de Salud Pública.

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: A systematic review and meta-analysis.

The aim of this study was to investigate whether interventions to discontinue or down-titrate heart failure (HF) pharmacotherapy are feasible and associated with risks in older people. A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to 8 March 2023. Randomized controlled trials (RCTs) and observational studies included people with HF, aged ≥50 years and who discontinued or down-titrated HF pharmacotherapy. Outcomes were feasibility (whether discontinuation or down-titration of HF pharmacotherapy was sustained at follow-up) and associated risks (mortality, hospitalization, adverse drug withdrawal effects [ADWE]). Random-effects meta-analysis was performed when heterogeneity was not substantial (Higgins I2 < 70%). Sub-analysis by frailty status was conducted. Six RCTs (536 participants) and 27 observational studies (810 499 participants) across six therapeutic classes were included, for 3-260 weeks follow-up. RCTs were conducted in patients presenting with stable chronic HF. Down-titrating a renin-angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% more likely than continuation (risk ratio [RR] 1.76, 95% confidence interval [CI] 1.14-2.73), with no difference in mortality (RR 0.64, 95% CI 0.30-1.64). Discontinuation of beta-blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95% CI 0.68-1.47). Participants were 25% more likely to re-initiate discontinued diuretics (RR 0.75, 95% CI 0.66-0.86). Digoxin discontinuation was associated with 5.5-fold risk of hospitalization compared to continuation. Worsening HF was the most common ADWE. One observational study measured frailty but did not report outcomes by frailty status. The appropriateness and associated risks of down-titrating or discontinuing HF pharmacotherapy in people aged ≥75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.

The evolution of evidence-based medicine.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Rethinking Surgical Margins: A New Approach to Predict Outcomes in Oral Squamous Cell Carcinoma.

OBJECTIVE: The traditional categorical division of surgical margins using a 5 mm cutoff in oral cavity squamous cell carcinoma (OCSCC) is controversial. The primary aim of this study was to investigate the presence of an optimal cutoff point or, alternatively, assess the potential improvement in predictive value by considering the surgical margins as a continuum. METHODS: Retrospective analysis of OCSCC patients at a tertiary medical center in 1995-2020. Clinical, pathological, and surgical data were evaluated for effect on survivability by regression analyses. RESULTS: The cohort included 266 patients (48.1% male, mean age 65.4 ± 17.7). Patient stratification by categorical margin status yielded no significant between-group differences in survival (p = 0.54). Significance was achieved when margin distance was reevaluated as a continuous variable (p = 0.0018). Similar results were shown in local control (categorical p = 0.59 vs. continuous p = 0.06). Multivariate model excluded possible confounders. A predictive model was created to provide a more accurate prediction of survival. CONCLUSIONS: The continuum spectrum of margin distance better predicts survival outcomes and locoregional control in OCSCC. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

11. Cervicogenic headache and occipital neuralgia.

INTRODUCTION: Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points. METHODS: The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized. RESULTS: Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON. CONCLUSION: The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.

Direct Composite Restorations on Permanent Teeth in the Anterior and Posterior Region - An Evidence-Based Clinical Practice Guideline - Part 1: Indications for Composite Restorations.

PURPOSE: This German S3 clinical practice guideline offers evidence-based recommendations for the use of composite materials in direct restorations of permanent teeth. Outcomes considered were the survival rates and restoration quality and process quality of the manufacturing process. Part 1 of this two-part presentation deals with the indication classes. MATERIALS AND METHODS: A systematic literature search was conducted by two methodologists using MEDLINE and the Cochrane Library via the OVID platform, including studies up to December 2021. Six PICO questions were developed to guide the search. Recommendations were formulated by a panel of dental professionals from 20 national societies and organizations based on the collected evidence. RESULTS: Composite materials are a viable option for the direct restoration of cavity Classes I-V and may also be used for restorations with cusp replacement, and tooth shape corrections. In the posterior region, direct composite restorations should be preferred over indirect composite inlays. For Class V restorations, composite materials can be used if adequate contamination control and adhesive technique are ensured. CONCLUSION: The guideline is the first to provide comprehensive evidence on the use of direct composite materials. However, further long-term clinical studies with comparators such as (modified) glass-ionomer cements are necessary. Regular updates will detail the future scope and limitations of direct composite restorations.

[Aflibercept in the clinical routine: the AURIGA study : The 24-month results of the German cohort of treatment-naïve patients with diabetic macular edema receiving intravitreal aflibercept]. / Aflibercept im klinischen Alltag: die AURIGA-Studie : 24-Monats-Ergebnisse der deutschen Kohorte behandlungsnaiver Patienten mit diabetischem Makulaödem unter Therapie mit intravitrealem Aflibercept.

BACKGROUND: AURIGA is the largest prospective real-world study to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema (DME) and macular edema secondary to retinal vein occlusion. This article presents 24-month data from the German cohort of treatment-naïve patients with DME. METHODS: Treatment-naïve patients (≥ 18 years) with DME were treated with IVT-AFL at the discretion of the physician in clinical practice. The primary endpoint was mean change in visual acuity (early treatment diabetic retinopathy, ETDRS, letters) at month 12 compared to baseline. Statistical analyses were descriptive. RESULTS: The analysis included data from 150 DME patients (54.7% male). At months 6, 12 and 24, mean (95% confidence interval) visual acuity gains of 4.6 (2.6; 6.5), 4.0 (2.1; 6.5) and 5.0 (3.0; 6.9) letters from baseline (mean ±SD: 65.0 ± 15.3 letters) and reductions in retinal thickness of 86µm (109; 64µm), 70µm (94; 43µm) and 75µm (103; 47µm) from baseline (mean ±SD: 391 ± 132 µm), respectively, were achieved. At month 24, 54% of patients gained ≥ 5 letters and 22% ≥ 15 letters. Patients received a mean number of 5.0 ± 1.6 injections until month 6, 7.1 ± 3.2 until month 12 and 9.0 ± 5.3 until month 24, 68% of patients received ≥ 5 injections until month 6 and 56% ≥ 7 injections within the first year. The safety profile was consistent with previous studies. DISCUSSION: In the German AURIGA cohort, treatment-naïve DME patients achieved a clinically relevant gain in visual acuity as well as reduction in central retinal thickness following IVT-AFL treatment in clinical practice. From month 6 onwards, improvements were maintained despite a low injection frequency over 24 months. In comparison with previous real-world studies, care of DME patients in clinical practice seems to have improved; however, there is still room for further improvement.