Cardiac rehabilitation (CR) can reduce mortality and morbidity through assisting patients in regaining physical and psychosocial well-being. CR is effective yet uptake rates are 44%. Of non-attenders, 30% expressed a ‘lack of interest’; the focus of this thesis’ question ‘What strategy would improve uptake of CR in invited patients.’
A sequential, multi-method approach was used. Literature reviews, assessing strategies to increase CR uptake and participation in other health services, found similar intervention designs, such as peers or health behaviour theory-based (HBT). An e-survey explored invitation strategies in CR practice and confirmed letters are used and low-cost. An advancement of theory-based letters is valuable but little is known about the operationalisation of HBT. Telephone interviews were conducted to explore the latter through patients’ viewpoints. A quasi-experiment evaluated the amended letters.
One review found six RCTs testing peer support, professional support (or combined) and letters, the latter two increased attendance. Twenty-three reviews on strategies promoting participation support access-enhancing methods, organisational changes, letters and calls. 190 CRPs indicated that multiple invitation strategies including in- hospital (70%), telephone (70%), letters (50%) are used; variations exist. Feasibility considerations supported the development of existing HBT letters. Interviews revealed a preference for less authoritative content outlining positive effects. Of 6 sites, with different organisational structure, 1 increased CR uptake using the new letter.
The amended theory-based letter had limited impact in CR uptake perhaps due to extrinsic factors, the letter itself or methodological issues. CR is a fragmented service and results highlight the importance of context-sensitive policies.
Summary Background and objectives We aimed to determine the risk of complications during cutaneous surgery for the perioperative discontinuation in comparison to the continuation of antithrombotic agents and the bridging of vitamin K antagonists with heparin in comparison to their continuation. Methods We conducted a systematic review, searching three databases for eligible studies. Methods followed the Cochrane Handbook. We used RoB 2 and ROBINS‐I to assess risk of bias. The quality of evidence was judged (GRADE). Fixed‐effect meta‐analyses were performed. Results Two randomized‐controlled trials and 19 prospective cohort studies were included. It is uncertain whether, compared to its discontinuation, continuing acetylsalicylic acid (risk difference (RD) 0.004, 95 % confidence interval (CI) –0.003 to 0.019) perioperatively increases the risk of significant postoperative bleedings (SPB). Compared to its discontinuation, continuing phenprocoumon perioperatively may increase the risk of SPB (RD 0.02, 95 % CI 0.00 to 0.05). Bridging phenprocoumon with heparin perioperatively may increase the risk of SPB when compared to its continuation (RD 0.07, 95 % CI 0.01 to 0.22). No evidence was found regarding bleeding risks for direct oral anticoagulants. Conclusions No clear indications of major risks of bleedings when continuing antithrombotic agents during minor skin surgeries were identified. However, the quality of evidence was very low.
The HELLP-syndrome is a severe complication in late pregnancy. The etiology is still largely unknown. It is defined as a separate disease but also as a severe course of EHP-gestosis. It is mainly characterised by increased liver enzymes, a low platelet count, increased haemolysis and hypertension. According to primary organ affection, neurological symptoms and acute respiratory distress syndrome, acute renal insufficiency and/or upper abdominal complaints may occur. The only causal therapy is immediate caesarean section. Postoperative intensive care must be guaranteed. As a gentle anaesthetic method neuroleptanalgesia is recommended. Based on 7 of our own case reports, pathophysiology and therapy are discussed.
Zusammenfassung Die Lebenszeitprävalenz für Urtikaria, die zu den schweren allergischen Erkrankungen zählt, liegt bei nahezu 20%. Sie schränkt nicht nur die Lebensqualität der Betroffenen ein, sondern die generelle Leistungsfähigkeit in Beruf und Alltag. Die vorliegende Publikation ist der erste Abschnitt der Leitlinie Urtikaria. Dieser Teil der Leitlinie umfasst deren Klassifikation und Diagnostik unter Einbeziehung der wesentlichen Fortschritte in der Erforschung ihrer Ursachen, auslösenden Faktoren und Pathomechanismen. Zudem befasst sie sich mit Strategien zur ökonomischen Diagnostik der verschiedenen Unterformen der Urtikaria. Dies ist entscheidend für eine individuelle, patientenorientierte Therapie, die im zweiten Teil behandelt wird. Diese deutschsprachige Leitlinie wurde auf der Basis der internationalen englischsprachigen S3‐Leitlinie unter besonderer Berücksichtigung der medizinischen Gegebenheiten im deutschsprachigen Raum entsprechend den Kriterien der AWMF erstellt. Die Leitlinie beschreibt in diesem Abschnitt die Klassifikation der Urtikaria, wobei spontan auftretende Quaddeln und Schwellungen von Urtikariaformen mit induzierbaren Symptomen abgegrenzt werden. Urtikaria wird als plötzlich auftretende Quaddeln, Schwellungen oder beides definiert, ist dabei aber abzugrenzen von Zuständen bei denen Quaddeln als kurzfristiges Symptom auftreten, wie zum Beispiel bei der Anaphylaxie. Die Diagnostik stützt sich auf (eingeschränkte) Laboruntersuchungen, aber insbesondere auch die Anamnese. Darüber hinaus stehen validierte Instrumente zur Verfügung, die den Schweregrad, die Aktivität und den Verlauf erfassen.
After cessation of successful initial acne therapy, patients often experience flares. Consecutive maintenance treatment after successful induction therapy is promoted by guidelines; however, little is known about the efficacy/safety of different maintenance regimens. A systematic review on acne maintenance treatments was conducted. We identified 5 randomized controlled trials [RCTs; adapalene vs. vehicle or vs. no treatment (3 RCTs), adapalene/benzoyl peroxide (BPO) vs. vehicle, combination/monotherapy of minocycline (systemic)/tazarotene/placebo] and 3 non-RCTs on systemic isotretinoin, adapalene/BPO and azelaic acid. The results of adapalene versus vehicle/no treatment varied depending on the reported outcome. The ‘number of patients maintaining at least 50% improvement' counting inflammatory lesions/non-inflammatory lesions with adapalene was superior to vehicle (risk ratio, RR 1.24, 95% confidence interval, CI 1.08-1.43/RR 1.34, 95% CI 1.18-1.59). However, no significant differences were found in 2 of 3 RCTs for maintaining ‘clear/almost clear' or ‘mild acne' or on the global grading score. For the combination regimens of minocycline/tazarotene/placebo, no significant differences were found. Adapalene/BPO was superior to vehicle counting inflammatory lesions/non-inflammatory lesions (RR 1.61, 95% CI 1.31-1.99; RR 1.80, 95% CI 1.44-2.26). Due to the scarcity of studies, few conclusions can be drawn. More homogeneous outcome measures and specific maintenance study designs may lead to more robust findings.
Summary Psoriasis is a chronic inflammatory skin condition. Patient education may be one option to improve adherence and coping. The aim of this systematic review is to identify studies evaluating educational interventions for psoriasis patients. The review was conducted following the methods recommended by Cochrane. We searched seven databases, one trial register and three grey literature repositories. Data screening and extraction was performed independently by two reviewers. Cochrane Risk of Bias 2.0, ROBINS‐I, and NIH tools were used. Additionally, the APEASE criteria were applied. We evaluated 16 studies. Two randomized clinical trials (RCTs) evaluated patient‐practitioner or patient‐nurse one‐to‐one interventions, one RCT assessed a web‐based intervention and three RCTs reported group interventions taking place frequently; one RCT reported one‐off group sessions. The remaining RCT compared the healthcare professionals involved. The risk of bias rating ranged from “some concerns” to “high”. Three RCTs found an effect. We included four controlled clinical trials (CCTs), one of which had an effect. One of the four before‐and‐after‐studies warrants further investigation. Despite similarities in delivery mode across the interventions, patients who were eligible and settings in which interventions were delivered differed. Interventions that included an individual (one‐to‐one) session appeared to be successful. Two interventions seem suitable for adaptation using APEASE: the topical treatment program and motivational interviewing after climate therapy.
Summary The lifetime prevalence of urticaria, a severe allergic disease, is almost 20%. It not only limits the quality of life of those affected, but also their general performance at work and in their daily activities. This publication is the first section of the Urticaria Guideline. It covers the classification and diagnosis of urticaria, taking into account the major advances in research into its causes, triggering factors and pathomechanisms. It also addresses strategies for the efficient diagnosis of the different subtypes of urticaria. This is crucial for individual, patient‐oriented treatment, which is covered in the second part of the guideline, published separately. This German‐language guideline was developed according to the criteria of the AWMF on the basis of the international English‐language S3 guideline with special consideration of health system characteristics in the German‐speaking countries. This first part of the guideline describes the classification of urticaria, distinguishing spontaneously occurring wheals (hives) and angioedema from forms of urticaria with inducible symptoms. Urticaria is defined as sudden onset of wheals, angioedema, or both, but is to be distinguished from conditions in which wheals occur as a short‐term symptom, such as anaphylaxis. The diagnosis is based on (a limited number of) laboratory tests, but especially on medical history. In addition, validated instruments are available to measure the severity, activity and course of the disease.
Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.
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