Amir Qaseem, MD, PhD, from ACP in Philadelphia, and colleagues developed clinical guidelines based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients’ values and preferences, and costs for type 2 diabetes treatments. The effectiveness and harms of newer pharmacologic treatments, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins were reviewed.

For adults with type 2 diabetes and inadequate glycemic control, the authors recommend the addition of an SGLT-2 inhibitor or GLP-1 agonist to metformin and lifestyle modifications (strong recommendation). An SGLT-2 inhibitor can reduce the risk for all-cause mortality, major adverse cardiovascular events, chronic kidney disease progression, and hospitalization due to congestive heart failure. Use of a GLP-1 agonist can reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. To reduce morbidity and all-cause mortality, the addition of a DPP-4 inhibitor to metformin and lifestyle modification is not recommended for adults with type 2 diabetes and inadequate glycemic control (strong recommendation).

“ACP continues to recommend starting treatment with metformin and adding other agents only when glycemic goals are not met or comorbid conditions warrant their use,” Fatima Z. Syed, M.D., from Duke University in Durham, North Carolina, writes in an accompanying editorial.

Abstract/Full Text

Editorial (subscription or payment may be required)

Review 1

Review 2

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Scott W. Young, MD, from Mayo Clinic Arizona in Phoenix, and colleagues conducted a comprehensive literature review combined with a modified Delphi technique to achieve a consensus for recommendations to improve the screening process for endometriosis.

The authors defined the target screening population, described techniques for enhancing pelvic ultrasound, established direct and indirect observation for endometriosis at ultrasound, created an observational grading and reporting system, and made recommendations for imaging and management of patients. To improve detection of endometriosis, recommendations include transvaginal ultrasound of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver. These techniques can be performed in 5 minutes or less and could reduce the delay of diagnosis in at-risk patients.

“The purpose of this consensus panel is to recommend methods that increase the diagnostic sensitivity for endometriosis on pelvic ultrasound by increasing awareness, improving interpretation, adding simple techniques that are high yield for deep endometriosis, and improving protocols to triage patients,” Young said in a statement.

Several authors disclosed ties to the pharmaceutical, publishing, and medical technology industries; two authors hold patents.

Abstract/Full Text

The practice advisory calls on doctors to test for syphilis at a pregnant woman’s first prenatal care visit, then again during the third trimester and at birth.

The advisory comes in response to a dramatic increase in syphilis rates among pregnant women and newborns.

Previously, ACOG recommended risk-based testing in the third trimester only for women living in communities with high rates of syphilis or women at high risk of becoming infected during pregnancy.

Syphilis can damage the heart and brain and cause blindness, deafness and paralysis unless it’s treated. When transmitted during pregnancy, it can cause miscarriage, lifelong health problems and infant death.

In February, the US Centers for Disease Control and Prevention reported that maternal syphilis rates had tripled in recent years.

More than 10,000 women who gave birth in 2022 had syphilis, up from about 3400 cases in 2016, the CDC found.

The ACOG advisory paints an even more dire picture, saying that US rates of babies born infected with syphilis had increased by 755% between 2012 and 2021.

“There has been a near eightfold increase in congenital syphilis cases in the last decade or more, and from a public health perspective, we recognize that obstetrician–gynecologists and other obstetric care clinicians play a critical role,” said Dr Christopher Zahn, ACOG’s interim CEO and chief of clinical practice and health equity and quality.

Notably, 2 in 5 infants born with syphilis had moms who didn’t receive any prenatal care, the advisory said.

“Therefore, it is important to make any health care encounter during pregnancy, including those in emergency departments, jails, syringe service programs and maternal and child health programs, an opportunity to screen for syphilis,” the advisory reads.

About 88% of syphilis cases in newborns could be prevented with timely screening and treatment, ACOG said.

“Timely diagnosis and treatment are key to reducing syphilis rates, and yet we are currently facing several challenges, including treatment shortages, lack of access to prenatal care and the stigma that surrounds sexually transmitted infections,” Zahn said in an ACOG news release. “Congenital syphilis can have devastating effects. We know that a majority of cases can be prevented, so additional routine screening during pregnancy is one important step that clinicians can take that could potentially be lifesaving.”

More information

The March of Dimes has more about syphilis in pregnancy.

SOURCE: American College of Obstetricians and Gynecologists, news release, April 18, 2024

“Hepatitis B virus vaccination is crucial for seronegative patients with advanced chronic kidney disease for protection during dialysis while preparing for transplantation,” according to Natavudh Townamchai, MD, of Chulalongkorn University and King Chulalongkorn Memorial Hospital in Bangkok, Thailand, and colleagues.

The investigators conducted a randomized controlled trial of patients with an estimated glomerular filtration rate (GFR) less than 30 mL/min/m², including those on dialysis. The standard HBV vaccination group received the Engerix B (40 μg) at 0, 4, 8, and 24 weeks. The accelerated group received the same 40 μg dose at 0, 1, 4, and 8 weeks. The 40μg dose is double the standard dosage given to the general population and is recommended in CKD guidelines.

Seroconversion was defined as titers of hepatitis B surface antibodies (anti-HBs) of 10 IU/L or higher. In intent-to-treat analyses of 133 patients, the accelerated group had significantly higher rates of seroconversion at 12 weeks compared with the standard group (83.08% vs 63.24%), Dr Townamchai’s team reported in Kidney International Reports. The accelerated group also exhibited a significantly higher seroconversion rate at 12 weeks (85.71% vs. 69.35%) in the per-protocol analysis of 125 patients. Based on the per-protocol analysis, for every 100 accelerated vaccinations, an additional 16 seroconversions would be expected compared with the standard vaccination schedule.

By 28 and 52 weeks, the seroconversion rates were similar between groups showing that the accelerated regimen produced a durable response. Rates of anti-HBs of 100 IU/L or greater correlate with longer protection. The investigators suggested that patients with anti-HBs titers below 100 IU/L should consider a booster HBV vaccination after 28 weeks.

No serious adverse events, such as anaphylaxis, occurred in the accelerated group.

“Seroconversion of anti-HBs in response to the vaccination can protect patients from HBV infection during dialysis and enable them to receive a kidney from an HBsAg-positive donor,” Dr Townamchai’s team pointed out.

IgA Nephropathy Progression

In a separate study of 1961 patients with biopsy-proven IgA nephropathy published in Kidney International Reports, Xu-jie Zhou, MD, of Peking University First Hospital, Peking University Institute of Nephrology, in Beijing, China, and colleagues reported that chronic hepatitis B infection significantly increased the risk for disease progression by 74%.

Use of antiviral medications against hepatitis B and resolved infection were not associated with the outcome. The presence of hepatitis B virus deposits in the kidney also did not appear prognostic.

“Our findings highlight the importance of considering HBV infection status when managing patients with IgAN and call for further research to elucidate underlying mechanisms and investigate potential benefits of targeted antiviral therapy in individuals with concomitant HBV infection and IgAN,” the investigators concluded.

Linnea M. Wilson, MPH, from the Beth Israel Deaconess Medical Center in Boston, and colleagues conducted a systematic review to identify clinical practice guidelines pertaining to BP management in the hospital for adult and older adult populations.

Fourteen guidelines met the inclusion criteria: 11 provided broad recommendations for BP management, and one each was specific to the emergency department setting, older adults, and hypertensive crises. The researchers found that none of the guidelines provided goals for inpatient BP or recommendations for management of inpatient asymptomatic moderately elevated BP. Hypertensive urgency was defined as BP greater than 180/120mm Hg in 6 guidelines, with the addition of target organ damage defining hypertensive emergencies. Recommendations consistently included use of intravenous antihypertensives in intensive care settings for hypertensive emergencies. Inconsistent recommendations were seen for managing hypertensive urgencies, and these focused on the emergency department. Outpatient BP goals were clearly defined and ranged from 130/80 to 140/90mm Hg.

“There is an urgent need for pragmatic clinical trials to fill knowledge gaps for the management of elevated BP in hospitalized adults as well as a need for the development of inpatient BP clinical decision-making frameworks that address the unique issues posed by hospitalization and care transitions,” the authors write.

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First-Line Therapy

For patients with Child-Pugh class A advanced HCC who have an ECOG performance status score of 0 or 1, the guidelines recommend atezolizumab plus bevacizumab or durvalumab plus tremelimumab as first-line treatment (a strong recommendation based on moderate- to high-quality evidence).

Patients with contraindications to atezolizumab plus bevacizumab or durvalumab plus tremelimumab can receive sorafenib, lenvatinib, or durvalumab as alternatives (a strong recommendation based on moderate-quality evidence).

Second-Line Therapy

For patients with Child-Pugh class A advanced HCC who have good performance status, recommendations for second-line treatment vary based on the first-line treatment a patient received.

Patients who received first-line atezolizumab plus bevacizumab can receive any of the following second-line treatments:

• A tyrosine kinase inhibitor (TKI) — such as sorafenib, lenvatinib, or cabozantinib — or ramucirumab (a weak recommendation based on low-quality evidence)
• Nivolumab plus ipilimumab (supported by data from case series)
• Durvalumab plus tremelimumab. (There are no data to support this recommendation.)

If durvalumab plus tremelimumab is given in the first line, second-line therapy with a TKI is recommended (a weak recommendation based on low-quality evidence). Atezolizumab plus bevacizumab may also be considered, but there are no data to support this recommendation.

If a patient received sorafenib or lenvatinib in the first line, second-line therapy may consist of any of the following (a weak recommendation based on low-quality evidence):

• Another TKI (cabozantinib or regorafenib)
• Ramucirumab
• Nivolumab plus ipilimumab
• Durvalumab
• Atezolizumab plus bevacizumab (for patients who did not have access to this combination in the first line)
• Durvalumab plus tremelimumab (for patients who did not have access to this combination in the first line).

Pembrolizumab and nivolumab may also be options for patients who previously received sorafenib or lenvatinib.

Third-Line Therapy and Child-Pugh Class B HCC

For third-line therapy, patients with Child-Pugh class A disease and good performance status can receive any of the aforementioned agents, as long as they do not have an identical mechanism of action to prior therapies (weak recommendation based on low-quality evidence).

For patients with Child-Pugh class B disease and good performance status, health care providers should consider the patients’ underlying liver function, bleeding risk, presence of portal hypertension, extent of extrahepatic spread, tumor burden, and major vascular invasion. There are limited data to suggest that regimens typically used for Child-Pugh A disease can be beneficial in untreated patients with Child-Pugh B cirrhosis (weak recommendation based on low-quality evidence).

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

Meera Viswanathan, PhD, from the RTI-International-University of North Carolina at Chapel Hill Evidence-based Practice Center, and colleagues reviewed the evidence on primary care-feasible or referable interventions to prevent child maltreatment in a review including 25 trials with 14,355 participants. The researchers found that evidence from 11 studies with 5311 participants indicated there were no differences in the likelihood of reports to Child Protective Services within 1 year of intervention completion; 5 studies with 3336 participants found no differences in removal of the child from the home within 1 to 3 years of follow-up. No benefits were seen for emergency department visits in the short-term (under 2 years) and hospitalizations. For all other outcomes, the evidence was inconclusive. Neither of the two trials reporting harms indicated statistically significant differences.

Based on these findings, the USPSTF concludes that in children and adolescents younger than 18 years without signs or symptoms of a known exposure to maltreatment, the current evidence is inadequate for determining the balance of benefits and harms of primary care interventions to prevent child maltreatment (I statement).

“There is still not enough evidence on what can be done in primary care to prevent maltreatment before it occurs,” USPSTF member James Stevermer, MD, said in a statement. “The task force continues to urgently call for more research in this area.”

Evidence Report

Final Recommendation Statement

Editorial

AANA developed policies and procedures that align with best available evidence for treating patients taking GLP-1 receptor agonists, which increase insulin synthesis and secretion, suppress glucagon secretion, reduce food intake through appetite suppression, slow gastric emptying, and promote beta-cell proliferation.

Considerations related to preoperative use of GLP-1 receptor agonists include withholding medication on the day of surgery/procedure in the case of a daily dose or the week before surgery in the case of a weekly dose. At this point, there are no changes to fasting guidelines. However, improvements in outcomes have been reported with changes such as a longer fasting period or clear-liquid diet for one to three days before surgery. Gastric point-of-care ultrasound (POCUS) should be considered to assess gastric contents and aspiration risks; the gastric antrum should be visualized when performing POCUS. Where gastric contents are present, a volumetric assessment should be performed to stratify aspiration risks. GLP-1 receptor agonists should be restarted after the procedure at the next scheduled dose.

“Open communication between patients and the surgical team is important with regard to recommendations for withholding GLP-1 agonist medications prior to surgery,” Micah Walden, D.N.P., a member of the AANA Practice Committee, said in a statement. “As providers, we take that information into account to perform an individualized, case-by-case assessment and create a care plan that will keep the patient safe and comfortable before, during, and after the procedure.”

More Information

Americans planning to fly to other countries should consult their doctors at least 6 weeks before they leave, if they are unsure about whether they are up to date on their measles vaccines, the guidance now says.

That’s 2 weeks earlier than the 1 month advance notice the CDC said in November would be needed in order to have enough time to get vaccinated.

Russia and Malaysia have also been added to the CDC’s map of 46 countries now facing large measles outbreaks. However, the agency warns that the global rise in measles cases remains a threat in other parts of the world.

“Measles spreads rapidly and may become a risk to travelers in places not included on the list above. CDC recommends all travelers are fully vaccinated against measles when traveling to any international destination,” the agency stressed in its guidance.

In recent weeks, health authorities have ramped up their plea for Americans to get vaccinated before traveling this year.

Officials have cited recent outbreaks linked to travelers who were infected abroad and had been eligible to be vaccinated, CBS News reported.

Those include a cluster of cases reported over the winter in Philadelphia linked to an unvaccinated baby. The infant had been old enough to get a shot of the measles-mumps-rubella (MMR) vaccine.

Another occurred in Idaho, which state health authorities linked to an unvaccinated adult who traveled to Europe, CBS News reported.

“The World Health Organization has noted a significant increase in measles cases worldwide, with a 30-fold increase in Europe. This includes popular international tourist destinations for Americans, like England,” the CDC said in a report released earlier this month.

Two doses of MMR vaccine offers 97% protection against measles, the CDC says, while one dose offers 93% protection. The protection is lifelong, experts say.

Most Americans got two doses of the vaccine by the time they were 6, though vaccination rates have slipped in recent years.

In the US, state and local health authorities have announced at least 55 confirmed or suspected cases of measles so far this year across 17 states, CBS News reported.

That is close to the 58 total measles cases the CDC says were reported for all of 2023. The last peak of annual measles cases was in 2019, when 1274 infections were reported, CBS News reported.

Most new cases in the past week have been in Chicago, where health authorities have been trying to stem an outbreak in a migrant shelter. New infections have also been announced over the past week in California and Arizona.

A spokesperson for the California Department of Public Health told CBS News there were four reported measles cases statewide, and that “cases have been linked to travel to countries with epidemics in the wake of decreased routine immunization.”

Meanwhile, officials in Arizona’s Coconino County also announced a new case on March 11. Three previous infections were reported this year in Arizona’s Maricopa County, which includes Phoenix, but the new case wasn’t linked to those or to international travel, CBS News reported.

More information

The U.S. Centers for Disease Control and Prevention has more on the measles.

SOURCE: U.S. Centers for Disease Control and Prevention, news release, March 13, 2024; CBS News

Christina C. Chang, PhD, from Alfred Hospital in Melbourne, Australia, and colleagues updated guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of patients with cryptococcosis.

The authors note that accurate delineation of cryptococcosis clinical syndrome is important as it guides the choice and duration of antifungal treatment. In high-income settings, the most optimal induction therapy option for cryptococcal meningitis, disseminated cryptococcosis, and severe isolated pulmonary cryptococcosis is liposomal amphotericin B 3 to 4mg/kg daily and flucytosine 25mg/kg four times a day. Patients with HIV-associated cryptococcal meningitis in low-income settings are best treated with liposomal amphotericin B 10mg/kg as a single dose, with 14 days of flucytosine 25mg/kg four times a day and fluconazole 1200mg daily as induction therapy. Outcomes should be optimized by providing the most effective antifungal therapy while preventing, monitoring, and managing potential toxicity. Clinical relapse should be expected and monitored for and examined thoroughly for causality.

“More clinical research needs to be done in high-income settings, where host risk profiles are changing and an increasing array of presentations of cryptococcosis are being recognized, necessitating more nuanced and individualized treatment plans,” the authors write.

Several authors disclosed ties to the pharmaceutical industry.

Abstract/Full Text (subscription or payment may be required)

Amy Cantor, MD, MPH, from the Pacific Northwest Evidence-Based Practice Center at the Oregon Health & Science University in Portland, and colleagues conducted a systematic review on screening and supplementation for IDA and ID without anemia in pregnancy. Seventeen trials of routine maternal iron supplementation that reported outcomes for pregnant persons and infants were included in the review. The researchers found that compared with placebo, prenatal iron supplementation resulted in no differences in maternal quality of life, rates of gestational diabetes, or rates of maternal hemorrhage. Maternal iron supplementation also had no effect on rates of hypertensive disorders of pregnancy, cesarean delivery, preterm birth, infant low birth weight, or infants small for gestational age. No studies examined the benefits or harms of screening for ID or IDA during pregnancy.

Based on these findings, the USPSTF concludes that the current evidence is insufficient for assessing the balance of benefits and harms of screening asymptomatic pregnant adolescents and adults for ID and IDA to prevent adverse maternal and infant health outcomes (I statement). Furthermore, the evidence is insufficient for assessing the balance of benefits and harms of routine iron supplementation in pregnancy for preventing adverse maternal and infant health outcomes (I statement).

The draft recommendation statement and evidence review have been posted for public comment. Comments can be submitted from February 27 through March 25.

Draft Evidence Review

Draft Recommendation Statement

Comment on Recommendation Statement

Paula P. Schnurr, PhD, from the National Center for PTSD in White River Junction, Vermont, and colleagues summarize the 2023 CPG and its development process for management of PTSD and acute stress disorder. Twelve key questions were developed and reviewed; recommendations were made after evaluation of the evidence.

Thirty-four recommendations in 5 topic areas were included in the revised CPG: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of PTSD with co-occurring conditions. The researchers found that the 6 recommendations on PTSD treatment were rated as strong. Use of specific manualized psychotherapies is recommended over pharmacotherapy; other recommendations include prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when other options are unavailable and the therapy has been validated for use with video teleconferencing. There were recommendations against benzodiazepines, cannabis, and cannabis-derived product use.

“We suggest that providers use this guideline to support communication to improve the quality of care and enhance clinical outcomes for their patients,” the authors write.

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On behalf of the AGA, Anne F. Peery, MD, from the University of North Carolina at Chapel Hill, and colleagues developed guidelines to provide recommendations on use of fecal microbiota-based therapies in adults with recurrent C. difficile infection, severe to fulminant C. difficile infection, inflammatory bowel diseases, including pouchitis, and irritable bowel syndrome. The Evidence-to-Decision framework was used to develop recommendations and provide considerations for implementation in clinical practice.

The guideline panel developed 7 recommendations. The AGA suggests select use of fecal microbiota-based therapies upon completion of standard-of-care antibiotics to prevent recurrence among immunocompetent adults with recurrent C. difficile. Use of conventional fecal microbiota transplant is suggested in mildly or moderately immunocompromised adults with recurrent C. difficile infection. The AGA suggests against use of any fecal microbiota-based therapies to prevent recurrent C. difficile in severely immunocompromised adults. Select use of conventional fecal microbiota transplant is suggested for adults hospitalized with severe or fulminant C. difficile not responding to standard-of-care antibiotics. Except in the context of clinical trials, the AGA suggests against use of conventional microbiota transplant as treatment for inflammatory bowel diseases or irritable bowel syndrome.

“Fecal microbiota transplant is a safe and effective treatment with enough scientific evidence to be offered to most patients with two or more C. diff recurrences,” Peery said in a statement.

Abstract/Full Text

Rita R. Kalyani, MD, from the Johns Hopkins University School of Medicine in Baltimore, and colleagues examined gaps in the management of diabetes and its complications and identified tools needed for HCPs and PWD to address these challenges.

Priority targets for addressing challenges for PWD include effective communication during clinical interactions at diagnosis and through the disease course; addressing the emotional and psychosocial needs of PWD; navigating available therapeutic options and explaining complex regimens to support medication taking; and the use of telehealth in the appropriate clinical setting. The authors describe tools that are available to help HCPs, including guided communication styles for facilitating effective communication; guidance on preferred and nonpreferred language; clinical screening tools for assessing psychosocial conditions and directories to assist in referrals for mental health providers; patient education resources to help navigate aspects of living with diabetes, including pharmacotherapies; and checklists to determine the appropriateness of telehealth use for individual patients.

“In the ever-changing landscape of diabetes and its management, both health care providers and people with diabetes will continue to need new and evolving tools to help address the common challenges they face,” Kalyani said in a statement.

Several authors disclosed ties to the biopharmaceutical and other industries.

Abstract/Full Text

Noting that children’s physical and mental health are threatened by climate change, Samantha Ahdoot, MD, from the University of Virginia School of Medicine in Charlottesville, and colleagues developed recommendations for climate change actions necessary to protect children now and in the future.

The authors recommend that climate change counseling be incorporated into clinical practice. Climate risks should be assessed and solutions recommended when screening for and addressing social determinants of health. Families should be educated on regional climate and health risks and protective strategies. To adequately prepare physicians to provide appropriate health care for children, climate, health, and equity curricula should be incorporated into medical school, residency, continuing education, and board examinations. Carbon emissions should be reduced from the health sector through operating facilities on carbon-free energy sources; in addition, energy, water, and other resource efficiency should be improved in health care buildings and product manufacturing. Decarbonization should be incentivized by incorporating the carbon intensity of services into value-based health care metrics. Physicians should serve as role models for promoting sustainability in practice, including by embracing active transportation, reducing home energy use, transitioning to clean energy sources, and adopting a more plant-based diet.

“Climate solutions are the foundation of a healthy future for every child,” Ahdoot said in a statement.

Policy Statement

Technical Report

John R. Papp, PhD, from the CDC in Atlanta, and colleagues note that depending on whether the tests detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, the laboratory tests for T. pallidum can be categorized into nontreponemal and treponemal tests, respectively. To help differentiate between an untreated infection or a past infection that has been successfully treated, both types of tests must be used in conjunction. Newer serologic tests allow for laboratory automation but have to be used in an algorithm, which can include older manual serological tests. Direct detection of T. pallidum is continuing to evolve from microscopic examination of materials from lesions to molecular detection of T. pallidum.

“Additional point-of-care tests and data are needed to increase understanding of their performance in clinical and outreach settings,” the authors write. “Additional areas needed for research include well-designed prospective studies on point-of-care test performance in the context of screening algorithms, special patient populations, linkage to treatment and care, and cost-benefits so that recommendations can be made regarding performance and use in the United States.”

Abstract/Full Text

Fred A. Lado, MD, PhD, from the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, and colleagues conducted a literature review and identified 197 articles that were retained for data extraction. The evidence was reviewed by a panel of 41 stakeholders who then drafted recommendations.

Consensus was reached on 52 recommendations covering services provided by specialized epilepsy centers relating to inpatient services/epilepsy monitoring units, surgery, diagnostic evaluation, and outpatient services. The guidelines recommend that centers should offer genetic testing and counseling; focus on providing education and communication for patients; give more attention to those with special needs; employ care coordinators who can facilitate multidisciplinary care; provide mental health screening, since mental health concerns are more common among those with epilepsy; and address health disparities among patients with epilepsy.

“In addition to advances in medicine, there has been a shift toward addressing overall well-being beyond seizure management. This includes care for comorbid conditions like anxiety and depression, enhanced communication between the patient and care team, and addressing health disparities in the epilepsy community,” Lado said in a statement. “Expanded guidelines are also sorely needed to help centers and hospitals obtain the resources to provide this level of comprehensive care.”

Two authors disclosed ties to the pharmaceutical and medical technology industries.

Abstract/Full Text

Biogen discontinues Alzheimer disease treatment; the American Academy of Dermatology issues new acne vulgaris management guidelines; update for EUA-labeled Paxlovid availability; narcolepsy/ADHD treatment recalled; FDA warns against copycat eye drop products.

The new guidelines include 18 evidence-based recommendations and 5 good practice statements resulting from a systematic review conducted by an expert panel. For patients over the age of 9 years, strong recommendations were made for the use of topical therapies such as benzoyl peroxide and retinoids (eg, adapalene, tretinoin, tazarotene, trifarotene), either as monotherapy or combined. Topical antibiotics were also strongly recommended though not as monotherapy. A strong recommendation was made for fixed-dose topical combination therapies as these agents could help with adherence, and in some cases, may be less expensive than prescribing the individual components separately.

With regard to systemic antibiotics, the panel strongly recommended the use of doxycycline and conditionally recommended minocycline and sarecycline based on the available evidence. In general, oral antibiotics should be used concomitantly with benzoyl peroxide and other topical therapies. Limiting the use of systemic antibiotics to the shortest possible duration helps to reduce the development of antibiotic resistance and antibiotic associated complications.

Additional good clinical practices highlighted in the guidelines include the following:

• Intralesional corticosteroid injections may be used as an adjuvant therapy in patients with larger acne papules or nodules.
  • Consider use in patients at risk for acne scarring and for those who need rapid inflammation and pain improvement.
  • Risk of local adverse events may be minimized by using a lower concentration and volume of corticosteroid. 
• Isotretinoin is recommended for patients with severe acne or for those who have failed other oral and topical therapies.
  • Patients with psychosocial burden or acne scarring should be considered candidates for isotretinoin.
  • Monitoring of liver function tests and lipids should be considered in these patients, though complete blood count is not necessary in healthy individuals.
  • Pregnancy prevention is mandatory for patients of childbearing age.

Based on individual patient factors, conditional recommendations were also made for the use of topical clascoterone, topical salicylic acid, topical azelaic acid, and hormone therapies (eg, combined oral contraceptives, spironolactone).

The full report, which also includes information on physical modalities (eg, acne lesion extraction, chemical peels, laser and light-based devices, microneedle radiofrequency devices, photodynamic therapy), complementary and alternative therapies (eg, vitamins, botanical and plant-derived agents) and diet, is available here.

Cynthia Feltner, MD, MPH, from RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, and colleagues reviewed the evidence on screening for speech and language delay or disorders in children aged 5 years or younger to inform the USPSTF. Thirty-eight studies from 41 articles were included, with 9006 participants. The researchers found that none of the studies assessed the direct benefits of screening vs no screening. Consistently high sensitivity and specificity were found in three studies assessing parent-reported tools for expressive language skills. There was wide variation noted in the accuracy of other screening tools. Benefit was found for different measures of expressive language skills in 2 randomized controlled trials evaluating relatively intensive parental group training interventions; no difference was seen for any outcomes in one trial assessing a less intensive intervention.

Based on these findings, the USPSTF concludes that the current evidence is inadequate for assessing the balance of benefits and harms of screening for speech and language delay and disorders among children without signs or symptoms or parent/caregiver-reported concerns (I statement).

“In the absence of evidence, health care professionals should use their judgment when deciding whether or not to screen children who are not showing signs of speech and language delay and disorders,” USPSTF member Li LI, MD, PhD, MPH, from the University of Virginia School of Medicine in Charlottesville, said in a statement.

Evidence Report

Final Recommendation Statement

Editorial

Edward L. Barnes, MD, MPH, from the University of North Carolina at Chapel Hill, and colleagues developed recommendations for the prevention and treatment of pouchitis and cuffitis to support practitioners in their management of these conditions.

The guideline panel made 9 conditional recommendations. The AGA suggests using antibiotics for treatment of pouchitis in patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis. Probiotics are suggested for the prevention of recurrent pouchitis in patients who experience recurrent episodes of pouchitis that respond to antibiotics. Chronic antibiotic therapy is suggested to prevent recurrent pouchitis in patients who experience recurrent pouchitis that responds to antibiotics but relapses after stopping antibiotics; however, advanced immunosuppressive therapies approved for treatment of inflammatory bowel disease are suggested for patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy. Advanced immunosuppressive therapies are also suggested for patients with recurrent pouchitis with inadequate response to antibiotics; corticosteroids can also be considered for these patients.

“As providers we struggle to get insurance approval for medications to treat pouchitis, because it has not been a well-defined or recognized entity,” coauthor Siddharth Singh, MD, from the University of California San Diego in La Jolla, said in a statement. “Our intention with this guideline is to help improve access for patients and providers to use these advanced therapies.”

Several authors disclosed ties to the pharmaceutical industry.

Abstract/Full Text

William A. Zoghbi, MD, from Houston Methodist Hospital, and colleagues noted that for initial evaluation and management of PHVs, echocardiography is the modality of choice. To assess valve structure and function, a comprehensive approach is needed. For evaluating prosthetic valve function and related complications, color and spectral Doppler play a central role. Assessment of prosthetic valve function is more challenging than native valves due to suboptimal visualization of prosthetic valve structure and occluder devices with transthoracic echocardiography and the inherent variability of valve hemodynamics and orifice areas seen with the wide range of prosthetic valve types and sizes.

Advanced imaging is often needed in patients with suspected prosthetic valvular dysfunction to identify the mechanism of dysfunction or severity of regurgitation. Computed tomography (CT) and cardiovascular magnetic resonance (CMR) have emerged as powerful imaging modalities that complement echocardiography in addition to the traditional role of two-dimensional and three-dimensional (3D) transesophageal echocardiography for assessing valve dysfunction. CT offers high-resolution imaging with a specific advantage in mechanical valves; the main strength of CMR is quantitation of the severity of regurgitation.

“This new guideline on prosthetic valves was very much needed, as the field has changed so much since 2009, with the introduction of percutaneous valves and improvements in 3D echocardiography and multimodality imaging,” Zoghbi said in a statement.

Several authors disclosed ties to the pharmaceutical and medical device industries.

Abstract/Full Text

Noting that increasing alcohol use during the past decade has resulted in rapid growth of the ALD-related health care burden, Loretta L. Jophlin, MD, PhD, from the University of Louisville Health in Kentucky, and colleagues developed clinical guidelines for ALD.

The authors note that alcohol-associated hepatitis (AH) is a unique phenotype of advanced disease, presenting with rapid onset or worsening of jaundice and acute-on-chronic liver failure, which conveys a one-month mortality risk of 20 to 50% in severe forms. The most accurate score for stratifying AH severity is the Model for End-Stage Disease Score. For patients with severe AH, the only available therapeutic with proven efficacy is corticosteroids, providing survival benefit at one month in 50 to 60% of patients. For ALD patients with concurrent alcohol use disorder (AUD), abstinence of alcohol use is challenging to achieve. Patients with ALD are rarely treated for AUD; strategies to overcome barriers to treatment are needed, and a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers should be promoted. In selected patients with AH who are unresponsive to medical therapy and have a low risk for relapse to posttransplant alcohol use, liver transplantation should be considered.

“Policy aimed at alcohol use reduction, multidisciplinary care of the dual diagnoses of AUD and ALD, and refinement of liver transplantation algorithms for patients with severe AH are areas where research should be focused,” the authors write.

Several authors disclosed ties to the pharmaceutical industry.

Abstract/Full Text

Derek K. Chu, MD, PhD, from McMaster University in Hamilton, Ontario, Canada, and colleagues agreed upon 25 recommendations to gain and maintain control of mild, moderate, and severe AD. The recommendations addressed optimal use of topical treatments, dilute bleach baths, dietary avoidance/elimination, allergen immunotherapy, and systemic treatments.

Changes in this update included guidance on shared decision-making and factors to consider for each of the recommendations. For patients with uncontrolled AD despite moisturizer use, use of topical corticosteroids or topical calcineurin inhibitors (TCIs) is recommended. The safety of TCIs is highlighted with typical use once or twice daily. Once-daily dosing of topical medications can be considered. Crisaborole 2 percent ointment is suggested for mild-to-moderate AD; for patients with mild-to-moderate AD refractory to moisturization alone, there is a suggestion against adding topical Janus kinase inhibitors. For AD alone with no infection, there is a suggestion against use of topical antimicrobials. Bleach baths are suggested as an additive therapy for patients with AD with moderate-to-severe disease, but not for those with mild AD. Elimination diets are not suggested for AD. For moderate-to-severe AD, allergen immunotherapy is suggested.

“The guidelines emphasize, in addition to standards of trustworthiness, the third principle of evidence-based medicine: that evidence alone is never enough; that patient values and preferences are crucial to arriving at optimal recommendations,” Chu said in a statement.

Atopic Dermatitis (Eczema) Guidelines

Ashwin N. Ananthakrishnan, MBBS, from Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues developed guidelines relating to the use of biomarkers for managing CD. Evidence on the performance of fecal calprotectin, serum C-reactive protein (CRP), and Endoscopic Healing Index was reviewed.

The authors developed 11 conditional recommendations. The panel suggested use of a biomarker- and symptom-based monitoring strategy over symptoms alone for patients with CD in symptomatic remission; a fecal calprotectin less than 150µg/g and normal CRP rules out active inflammation, avoiding the need for endoscopic evaluation for assessment of disease activity. In this setting, elevated biomarkers warrant confirmation with endoscopy before adjustment of treatment. Neither normal nor elevated biomarkers alone are sufficiently accurate to determine endoscopic activity in patients with CD with mild symptoms. Elevated fecal calprotectin or serum CRP suggests endoscopic activity, precluding routine endoscopic assessment for disease activity, in patients with moderate-to-severe symptoms. For patients with CD in surgically induced remission, a normal fecal calprotectin reliably rules out endoscopic recurrence in low-risk patients on pharmacologic prophylaxis. Endoscopic assessment is suggested for establishing postoperative recurrence in other postoperative settings.

“Based on this guideline, biomarkers are no longer considered experimental and should be an integral part of inflammatory bowel disease care,” Ananthakrishnan said in a statement. “Biomarkers are usually easier to obtain, less invasive, more cost-effective than frequent colonoscopies and can be assessed more frequently for tighter disease control.”

Several authors disclosed ties to the biopharmaceutical industry.

Clinical Practice Guideline