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ObjectiveThe aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010.MethodThe searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines.ResultsWe identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Purpose of ReviewTo provide an overview of the literature regarding the use of machine learning algorithms to predict hypertension. A systematic review was performed to select recent articles on the subject.Recent FindingsThe screening of the articles was conducted using a machine learning algorithm (ASReview). A total of 21 articles published between January 2018 and May 2021 were identified and compared according to variable selection, train-test split, data balancing, outcome definition, final algorithm, and performance metrics. Overall, the articles achieved an area under the ROC curve (AUROC) between 0.766 and 1.00. The algorithms most frequently identified as having the best performance were support vector machines (SVM), extreme gradient boosting (XGBoost), and random forest.SummaryMachine learning algorithms are a promising tool to improve preventive clinical decisions and targeted public health policies for hypertension. However, technical factors such as outcome definition, availability of the final code, predictive performance, explainability, and data leakage need to be consistently and critically evaluated.

Purpose of ReviewHypertension is the primary risk factor for cardiovascular disease and adequate blood pressure control is often elusive. The objective of this work was to conduct a meta-analysis of trial data of isometric resistance training (IRT) studies in people with hypertension, to establish if IRT produced an anti-hypertensive effect. A database search (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and MEDLINE) identified randomised controlled and crossover trials of IRT versus a sedentary or sham control group in adults with hypertension.Recent FindingsWe included 12 studies (14 intervention groups) in the meta-analyses, with an aggregate of 415 participants. IRT reduced systolic blood pressure (SBP), mean difference (MD) − 7.47 mmHg (95%CI − 10.10, − 4.84), P < 0.01; diastolic blood pressure (DBP) MD − 3.17 mmHg (95%CI − 5.29, − 1.04), P < 0.01; and mean arterial blood pressure (MAP) MD − 7.19 mmHg (95%CI − 9.06, − 5.32), P < 0.0001. Office pulse pressure and resting heart rate was not significantly reduced, neither were 24-h or day-time ambulatory blood pressures (SBP, DBP). Night-time blood pressures, however, were significantly reduced with SBP MD − 4.28 mmHg (95%CI − 7.88, − 0.67), P = 0.02, and DBP MD − 2.22 mmHg (95%CI − 3.55, − 0.88), P < 0.01.SummaryIRT does lower SBP, DBP and MAP office and night-time ambulatory SBP and DBP, but not 24-h mean ambulatory blood pressures in people with hypertension.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. “Pharmacological Treatments” is the third of six sections of the 2016 guidelines. With little new information on older medications, treatment recommendations focus on second-generation antidepressants. Results: Evidence-informed responses are given for 21 questions under 4 broad categories: 1) principles of pharmacological management, including individualized assessment of patient and medication factors for antidepressant selection, regular and frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents. Conclusions: Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.

In traditional medical education, learners are mostly trained to diagnose and treat patients through supervised practice. Artificial Intelligence and simulation techniques can complement such an educational practice. In this paper, we present GLARE-Edu, an innovative system in which AI knowledge-based methodologies and simulation are exploited to train learners “how to act” on patients based on the evidence-based best practices provided by clinical practice guidelines. GLARE-Edu is being developed by a multi-disciplinary team involving physicians and AI experts, within the AI-LEAP (LEArning Personalization of AI and with AI) Italian project. GLARE-Edu is domain-independent: it supports the acquisition of clinical guidelines and case studies in a computer format. Based on acquired guidelines (and case studies), it provides a series of educational facilities: (i) navigation , to navigate the structured representation of the guidelines provided by GLARE-Edu, (ii) automated simulation , to show learners how a guideline would suggest to act, step-by-step, on a specific case, and (iii) (self) verification , asking learners how they would treat a case, and comparing step-by-step the learner’s proposal with the suggestions of the proper guideline. In this paper, we describe GLARE-Edu architecture and general features, and we demonstrate our approach through a concrete application to the melanoma guideline and we propose a preliminary evaluation.

Technology‐aided remote interventions for poorly controlled symptoms may improve cancer symptom outcomes. In a randomized controlled trial, the efficacy of an automated symptom management system was tested to determine if it reduced chemotherapy‐related symptoms. Prospectively, 358 patients beginning chemotherapy were randomized to the Symptom Care at Home (SCH) intervention (n = 180) or enhanced usual care (UC) (n = 178). Participants called the automated monitoring system daily reporting severity of 11 symptoms. SCH participants received automated self‐management coaching and nurse practitioner (NP) telephone follow‐up for poorly controlled symptoms. NPs used a guideline‐based decision support system. Primary endpoints were symptom severity across all symptoms, and the number of severe, moderate, mild, and no symptom days. A secondary endpoint was individual symptom severity. Mixed effects linear modeling and negative binominal regressions were used to compare SCH with UC. SCH participants had significantly less symptom severity across all symptoms (P < 0.001). On average, the relative symptom burden reduction for SCH participants was 3.59 severity points (P < 0.001), roughly 43% of UC. With a very rapid treatment benefit, SCH participants had significant reductions in severe (67% less) and moderate (39% less) symptom days compared with UC (both P < 0.001). All individual symptoms, except diarrhea, were significantly lower for SCH participants (P < 0.05). Symptom Care at Home dramatically improved symptom outcomes. These results demonstrate that symptoms can be improved through automated home monitoring and follow‐up to intensify care for poorly controlled symptoms. We tested an automated system to decrease symptom burden during chemotherapy. Results are reported for a randomized controlled trial of Symptom Care at Home, an automated symptom monitoring and management system that included automated self‐management coaching coupled with oncology provider alerts about poorly controlled symptoms at home. Study‐based nurse practitioners provided telephone follow‐up utilizing a symptom care decision support system to intensify symptom care. The trial results clearly demonstrate that the intervention significantly improves symptom outcomes.

We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleedingFor patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy settingFor patients on warfarin, we suggest continuation as opposed to temporary interruption (1–7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y 12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y 12 receptor inhibitor for patients on a single P2Y 12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1–7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y 12 receptor inhibitor drugs because of insufficient evidence.

Purpose of ReviewHypertensive disorders of pregnancy affect about 5–10% of pregnancies impacting maternal, fetal, and neonatal outcomes. We review the recent studies in this field and discuss the pathophysiology, diagnosis, and management of hypertension during pregnancy, as well as the short- and long-term consequences on the cardiovascular health of women.Recent FindingsAlthough the American College of Cardiology/American Heart Association revised their guidelines for hypertension in the general population in 2017, hypertension during pregnancy continues to be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, measured on two separate occasions. The addition of stage 1 hypertension will increase the prevalence of hypertension during pregnancy, identifying more women at risk of preeclampsia; however, more research is needed before changing the BP goal because a lower target BP has a risk of poor placental perfusion. Women with chronic hypertension have a higher incidence of superimposed preeclampsia, cesarean section, preterm delivery before 37 weeks’ gestation, birth weight less than 2500 g, neonatal unit admission, and perinatal death. They also have a higher risk of developing cardiovascular disease later in life. The guidelines recommend low-dose aspirin for women with moderate and high risk of preeclampsia. While treating pregnant women with hypertension, the effectiveness of the antihypertensive agent must be balanced with risks to the fetus.SummaryHypertensive disorders of pregnancy should be appropriately and promptly recognized and treated during pregnancy. They should further be co-managed by the obstetrician and cardiologist to decrease the long-term negative impact on the cardiovascular health of women.

This meta-analysis examined the effect of probiotics on outcomes associated with cardiovascular disease risk factors (high blood pressure, overweight BMI, high cholesterol and triglycerides, elevated HbA1c and serum glucose). All randomised controlled trials publish on PubMed, Scopus, Embase, Grey Literature and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1990 to 2020 were systematically searched. The PEDro scale was used to assess the quality of studies. A total of 34 studies with 2177 adults were selected for inclusion in the analysis. The mean difference and effect size with a 95% confidence interval (CI) were analysed for the pooled results. Statistically significant pooled effects of probiotics were found in the reduction of systolic and diastolic blood pressure, total cholesterol, LDL-C, serum glucose, HbA1C and BMI; and elevation of HDL-C. No significant changes were observed in the outcome of triglycerides. Subgroup analysis revealed statistically significant effects of probiotics on the treatment of risk factors, with results favouring longer duration of treatment (> 1.5 months), use of alternate formulations (kefir and powder), higher dosage of probiotics (> 1.0 × 109 CFU), lower rate of study attrition (< 15%), double blinding of the study, diabetic patients and female populations. In summary, our meta-analysis showed a highly significant reduction in SBP, DBP associated with type 2 diabetes and in patients with diabetes mellitus, milk intake and more than 1.5 months duration intake. The effect on the reduction of total cholesterol LDL-C was associated with diabetes, hypertension, hypercholesterolemia, yoghurt intake and less than 1.5 months probiotic intake. The effect on the reduction of glucose and HbA1c was associated with diabetes, small dosage of probiotics, milk type and less than 1.5 months duration intake. Additionally, probiotic supplement had a beneficial effect in reducing BMI associated with obesity, higher dosage intake of probiotics and more than 1.5 months duration of intake.