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INTRODUCTION:Older people face higher risks of medicine-related harm due to polypharmacy and the use of potentially inappropriate medicines. Current treatment guidelines rarely specify when to stop medicines, leading to medicines often being continued indefinitely without a clear deprescribing plan. While deprescribing guidelines exist for some medicine classes, limited guidance is a major barrier to deprescribing. These new guidelines address this gap by providing structured recommendations that complement more detailed drug-specific deprescribing guidance, disease-specific therapeutic guidelines and non-pharmacological management resources. These guidelines were developed by a team of 72 experts, including consumer representatives, and were further shaped by feedback from public consultation and independent reviewers. MAIN RECOMMENDATIONS:The guidelines are intended for all healthcare professionals involved in prescribing, dispensing or administering medicines to older people. The guidelines specifically address polypharmacy and medicines commonly dispensed for regular use in people aged ≥ 65 years, as well as other medicines where there is evidence to consider deprescribing in this cohort. The guidelines provide 185 consensus-based recommendations and 70 good practice statements, covering both specific medicine categories and general deprescribing principles. The guidelines are structured into four areas: (1) when to deprescribe; (2) ongoing treatment needs; (3) how to deprescribe; and (4) monitoring requirements. CHANGES IN CARE AS A RESULT OF THE GUIDELINE:This guideline emphasises deprescribing as an integral part of the prescribing continuum. Applying a deprescribing approach encourages prescribers to consider the ongoing need for a medicine each time a prescription is re-issued, to balance benefits and harms as they evolve over time, and to ensure treatment decisions reflect an individual's goals through shared decision-making. The guideline was developed based on currently available evidence for deprescribing and expert multidisciplinary and consumer input. It supports health professionals in reviewing regular medicines, minimising harm and planning ongoing treatment or monitoring. The detailed guideline is available at https://deprescribing.com.
RATIONALE:Virtual reality applications have emerged as a treatment approach in stroke rehabilitation, with the first randomised trial published in 2004. A wide range of applications have been tested in research studies and adopted in clinical practice, from non-immersive, non-customised, interactive game-based applications to immersive applications specifically designed for rehabilitation settings. This is an update of a Cochrane review first published in 2011 and then again in 2015 and 2017. OBJECTIVES:Primary objective: to assess the effects of virtual reality compared with an alternative intervention or no intervention for upper limb function and activity in people after stroke. SECONDARY OBJECTIVES:to assess the effects of virtual reality compared with an alternative intervention or no intervention on gait and balance, global motor function, cognitive function, activity limitation, participation restriction and quality of life, and adverse events in people after stroke. SEARCH METHODS:We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, and four additional databases. We also searched trials registries up to September 2023. ELIGIBILITY CRITERIA:We included randomised trials in adults after stroke comparing virtual reality (an advanced form of human-computer interface that allows the user to 'interact' with a computer-generated environment in a naturalistic fashion) with alternative or usual care. We excluded studies that compared two different types of virtual reality without an alternative group and studies of participants with mixed aetiology (e.g. participants with acquired brain injury) unless data were available relating to people with stroke only. OUTCOMES:The critical outcome of interest was upper limb function and activity. Important outcomes included mobility outcomes (gait speed, balance), global cognitive function, activity limitation, participation restriction and quality of life, and adverse events. RISK OF BIAS:We used the Cochrane RoB 1 tool to assess risk of bias. SYNTHESIS METHODS:We conducted meta-analysis using a fixed-effect model to calculate the standardised mean difference (SMD) and 95% confidence intervals (CI) for the critical outcome. We assessed the certainty of the evidence using GRADE. INCLUDED STUDIES:We included 190 trials involving a total of 7188 participants, of which 119 studies are newly included in the current update. The majority of studies were small, with only 36 (19%) studies involving more than 50 participants, and the largest study recruiting 152 participants. Interventions varied in terms of both the goals of treatment and the virtual reality applications used. Control groups usually received the same amount of an alternative form of therapy. In many studies risk of bias was unclear due to poor reporting. Thus, while there is a very large number of randomised controlled trials included in the review, the evidence remains mostly low or moderate certainty when rated using the GRADE system. SYNTHESIS OF RESULTS:When comparing virtual reality with alternative therapy approaches, results suggest that virtual reality may be beneficial in slightly improving upper limb function and activity (SMD 0.20, 95% CI 0.12 to 0.28; 67 studies, 2830 participants; low-certainty evidence). When compared with alternative therapy approaches, virtual reality may have little to no effect on gait speed, but the evidence is very uncertain (10 studies, 304 participants; very low-certainty evidence). Compared to alternative therapy approaches, virtual reality may be slightly beneficial for balance (SMD 0.26, 95% CI 0.12 to 0.40; 24 studies, 871 participants; low-certainty evidence) and probably reduces activity limitation (SMD 0.21, 95% CI 0.11 to 0.32; 33 studies, 1495 participants; moderate-certainty evidence). However, there may be little to no effect on participation and quality of life (SMD 0.11, 95% CI -0.02 to 0.24; 16 studies, 963 participants; low-certainty evidence). The addition of virtual reality to usual care or rehabilitation (resulting in an increased amount of time spent in therapy for those in the intervention group) probably increases upper limb function and activity compared to usual care alone (SMD 0.42, 95% CI 0.26 to 0.58; 21 studies, 689 participants; moderate-certainty evidence). However, there may be no apparent benefit in gait speed, but the evidence is very uncertain (3 studies, 57 participants; very low-certainty evidence). Virtual reality in addition to usual care may be beneficial for balance (SMD 0.68, 95% CI 0.46 to 0.91; 12 studies, 321 participants; low-certainty evidence) and is probably beneficial for activity limitation (SMD 0.22, 95% CI 0.04 to 0.41; 15 studies, 513 participants; moderate-certainty evidence). The evidence suggests that virtual reality in addition to usual care may not have a beneficial effect on participation and quality of life (2 studies, 76 participants; low-certainty evidence). Fifty-nine studies in this review reported that they monitored for adverse events; across these studies there were few adverse events, and those reported were relatively mild. AUTHORS' CONCLUSIONS:We found moderate- to low-certainty evidence that the use of virtual reality and interactive video gaming is slightly more beneficial than alternative therapy approaches in improving upper limb function, balance, and activity limitation. Furthermore, greater benefits were seen for upper limb function when virtual reality was used in addition to usual care (to increase overall therapy time). There was mixed evidence on the effects on mobility outcomes including gait speed, and insufficient evidence to reach any conclusions about the effect of virtual reality and interactive video gaming on participation restriction and quality of life. FUNDING:This Cochrane review had no dedicated funding. REGISTRATION:Protocol: doi.org/10.1002/14651858.CD008349 Original review (2011): doi.org/10.1002/14651858.CD008349.pub2 Review update (2015): doi.org/10.1002/14651858.CD008349.pub3 Review update (2017): doi.org/10.1002/14651858.CD008349.pub4.
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV) are traditionally diagnosed by positive ANCA on indirect immunofluorescence (IIF) slides, followed by confirmatory specific immunoassay for myeloperoxidase (MPO) or proteinase-3 (PR3) antibodies. These immunoassays are reportedly highly sensitive and specific for AAV diagnosis; however, this may vary depending on platform used. Due to locally observed cases of false-positive results, we sought to assess the performance characteristics of the ImmunoCAP fluorescent enzyme immunoassay (FEIA) for detection of MPO/PR3 antibodies. All positive MPO/PR3 antibody results via FEIA over a 5-year period were collated at Central Sydney Immunopathology Laboratory. We analysed electronic medical records to identify the associated clinical diagnosis for all cases, including those known to contribute to MPO/PR3 positivity, such as inflammatory bowel disease (IBD), cocaine use, and antithyroid medications. Potential confounding laboratory results, which may contribute to false-positive results (e.g., paraprotein, rheumatoid factor, anti-cardiolipin IgG) were also collected. We excluded cases where no clinical data were available, and cases where age was under 18 years. Local ethics board approval was granted for this study. Only 84 of 222 (37.8%) patients with a positive MPO or PR3 autoantibody had a diagnosis of AAV. Of the 138 cases without a diagnosis of AAV, 72 (52.2%) had IBD. All IBD cases had positive PR3 antibodies but were noted to have lower levels (mean = 8.8 U/mL) than those associated with AAV (mean = 30.0; p value <0.05). Only 11 PR3-positive IBD patients had a corresponding c-ANCA-positive pattern. We found 20% (n = 66) of cases had neither AAV nor IBD, of which 29 had a laboratory abnormality that may contribute to laboratory interference and false-positive results. We found a high rate of false-positive results for MPO/PR3 antibodies via the ImmunoCAP FEIA in the real-world laboratory setting. Our results support the importance of correlating these results with IIF, clinical findings, and biopsy diagnosis and emphasise the need for clinician education to ensure ANCA testing is performed only where there is a high pre-test probability of AAV.
Recent studies have shown high early failure rates with Cup Cage constructs in complex revision surgery for Paprosky 3B acetabular defects. As a result, the use of 3D printed custom-made acetabular components has become more common. In this case series, we present two cases that demonstrate the latest advancement in 3D printed implants for severe acetabular bone loss. The follow up was 3 and 7 years. Neither patient has undergone revision surgery of the acetabular component to date. One patient sustained a femoral peri-prosthetic fracture requiring plate fixation. This case study demonstrates that 3D printed implants have excellent intraoperative and immediate postoperative outcomes in revision surgery for severe acetabular bone defects.
Incidence of total hip arthroplasties being performed is on a rise across the world, consequently we would see more and more revisions hip arthroplasties being done for various indications such as infection, loosening, wear, metallosis, trauma; alone or a combination of the above factors. This case report highlights one of the rare but interesting scenarios that a revision hip surgeon must be prepared to encounter while planning to perform a technically challenging revision hip arthroplasty surgery. This report also thus emphasizes the importance of extensive pre-operative planning in terms of technique and timing of the procedure, the skills set and the armamentarium of tools that may be needed for a demanding revision arthroplasty procedure.
