BACKGROUND Successful management of chronic cough has varied in the primary research studies in the reported literature. One of the potential reasons relates to a lack of intervention fidelity to the ...core elements of the diagnostic and/or therapeutic interventions that were meant to be used by the investigators. METHODS We conducted a systematic review to summarize the evidence supporting intervention fidelity as an important methodologic consideration in assessing the effectiveness of clinical practice guidelines used for the diagnosis and management of chronic cough. We developed and used a tool to assess for five areas of intervention fidelity. Medline (PubMed), Scopus, and the Cochrane Database of Systematic Reviews were searched from January 1998 to May 2014. Guideline recommendations and suggestions for those conducting research using guidelines or protocols to diagnose and manage chronic cough in the adult were developed and voted upon using CHEST Organization methodology. RESULTS A total of 23 studies (17 uncontrolled prospective observational, two randomized controlled, and four retrospective observational) met our inclusion criteria. These articles included 3,636 patients. Data could not be pooled for meta-analysis because of heterogeneity. Findings related to the five areas of intervention fidelity included three areas primarily related to the provider and two primarily related to the patients. In the area of study design , 11 of 23 studies appeared to be underpinned by a single guideline/protocol; for training of providers , two of 23 studies reported training, and zero of 23 reported the use of an intervention manual; and for the area of delivery of treatment , when assessing the treatment of gastroesophageal reflux disease, three of 23 studies appeared consistent with the most recent guideline/protocol referenced by the authors. For receipt of treatment , zero of 23 studies mentioned measuring concordance of patient-interventionist understanding of the treatment recommended, and zero of 23 mentioned measuring enactment of treatment , with three of 23 measuring side effects and two of 23 measuring adherence. The overall average intervention fidelity score for all 23 studies was poor (20.74 out of 48). CONCLUSIONS Only low-quality evidence supports that intervention fidelity strategies were used when conducting primary research in diagnosing and managing chronic cough in adults. This supports the contention that some of the variability in the reporting of patients with unexplained or unresolved chronic cough may be due to lack of intervention fidelity. By following the recommendations and suggestions in this article, researchers will likely be better able to incorporate strategies to address intervention fidelity, thereby strengthening the validity and generalizability of their results that provide the basis for the development of trustworthy guidelines.
BACKGROUND This series of guidance documents on cough, which will be published over time, is a hybrid of two processes: (1) evidence-based guidelines and (2) trustworthy consensus statements based on ...a robust and transparent process. METHODS The CHEST Guidelines Oversight Committee selected a nonconflicted Panel Chair and jointly assembled an international panel of experts in each clinical area with few, if any, conflicts of interest. PICO (population, intervention, comparator, outcome)-based key questions and parameters of eligibility were developed for each clinical topic to inform the comprehensive literature search. Existing guidelines, systematic reviews, and primary studies were assessed for relevance and quality. Data elements were extracted into evidence tables and synthesized to provide summary statistics. These, in turn, are presented to support the evidence-based graded recommendations. A highly structured consensus-based Delphi approach was used to provide expert advice on all guidance statements. Transparency of process was documented. RESULTS Evidence-based guideline recommendations and consensus-based suggestions were carefully crafted to provide direction to health-care providers and investigators who treat and/or study patients with cough. Manuscripts and tables summarize the evidence in each clinical area supporting the recommendations and suggestions. CONCLUSIONS The resulting guidance statements are based on a rigorous methodology and transparency of process. Unless otherwise stated, the recommendations and suggestions meet the guidelines for trustworthiness developed by the Institute of Medicine and can be applied with confidence by physicians, nurses, other health-care providers, investigators, and patients.
Background Cough among patients with lung cancer is a common but often undertreated symptom. We used a 2015 Cochrane systematic review, among other sources of evidence, to update the recommendations ...and suggestions of the American College of Chest Physicians (CHEST) 2006 guideline on this topic. Methods The CHEST methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on data from the Cochrane systematic review on the topic, uncontrolled studies, case studies, and the clinical context. Final grading was reached by consensus according to the Delphi method. Results The Cochrane systematic review identified 17 trials of primarily low-quality evidence. Such evidence was related to both nonpharmacologic (cough suppression) and pharmacologic (demulcents, opioids, peripherally acting antitussives, or local anesthetics) treatments, as well as endobronchial brachytherapy. Conclusions Compared with the 2006 CHEST Cough Guideline, the current recommendations and suggestions are more specific and follow a step-up approach to the management of cough among patients with lung cancer, acknowledging the low-quality evidence in the field and the urgent need to develop more effective, evidence-based interventions through high-quality research.
While anti-VEGF drugs are commonly used to inhibit pathological retinal and choroidal neovascularization, not all patients respond in an optimal manner. Mechanisms underpinning resistance to ...anti‑VEGF therapy include the upregulation of other proangiogenic factors. Therefore, therapeutic strategies that simultaneously target multiple growth factor signaling pathways would have significant value. Here, we show that Ca2+/calmodulin-dependent kinase II (CAMKII) mediates the angiogenic actions of a range of growth factors in human retinal endothelial cells and that this kinase acts as a key nodal point for the activation of several signal transduction cascades that are known to play a critical role in growth factor-induced angiogenesis. We also demonstrate that endothelial CAMKIIγ and -δ isoforms differentially regulate the angiogenic effects of different growth factors and that genetic deletion of these isoforms suppresses pathological retinal and choroidal neovascularization in vivo. Our studies suggest that CAMKII could provide a novel and efficacious target to inhibit multiple angiogenic signaling pathways for the treatment of vasoproliferative diseases of the eye. CAMKIIγ represents a particularly promising target, as deletion of this isoform inhibited pathological neovascularization, while enhancing reparative angiogenesis in the ischemic retina.
Background Unexplained chronic cough (UCC) causes significant impairments in quality of life. Effective assessment and treatment approaches are needed for UCC. Methods This systematic review of ...randomized controlled trials (RCTs) asked: What is the efficacy of treatment compared with usual care for cough severity, cough frequency, and cough-related quality of life in patients with UCC? Studies of adults and adolescents aged > 12 years with a chronic cough of > 8 weeks’ duration that was unexplained after systematic investigation and treatment were included and assessed for relevance and quality. Based on the systematic review, guideline suggestions were developed and voted on by using the American College of Chest Physicians organization methodology. Results Eleven RCTs and five systematic reviews were included. The 11 RCTs reported data on 570 participants with chronic cough who received a variety of interventions. Study quality was high in 10 RCTs. The studies used an assortment of descriptors and assessments to identify UCC. Although gabapentin and morphine exhibited positive effects on cough-related quality of life, only gabapentin was supported as a treatment recommendation. Studies of inhaled corticosteroids (ICS) were affected by intervention fidelity bias; when this factor was addressed, ICS were found to be ineffective for UCC. Esomeprazole was ineffective for UCC without features of gastroesophageal acid reflux. Studies addressing nonacid gastroesophageal reflux disease were not identified. A multimodality speech pathology intervention improved cough severity. Conclusions The evidence supporting the diagnosis and management of UCC is limited. UCC requires further study to establish agreed terminology and the optimal methods of investigation using established criteria for intervention fidelity. Speech pathology-based cough suppression is suggested as a treatment option for UCC. This guideline presents suggestions for diagnosis and treatment based on the best available evidence and identifies gaps in our knowledge as well as areas for future research.
Background
Long‐term benefits of exercise for people with Parkinson's disease (PD) require regular and sustained participation. This study aimed to investigate predictors of adherence to a minimally ...supervised exercise program designed to reduce falls in people with PD.
Method
People with idiopathic PD who participated in the exercise arm of a randomized, controlled trial were included. Exercises were prescribed three times per week for 6 months. Adherence was defined as the percentage of prescribed sessions participants reported as having undertaken. Potential predictors of adherence included baseline measures of demographic variables, disease severity and duration, falls and fear of falling, pain, self‐reported health and quality of life, cognition, physical activity levels, freezing of gait, functional mobility and balance, and knee extensor strength.
Results
The 108 participants included undertook a mean of 72% (standard deviation: 38%) of prescribed sessions. Participants had higher levels of adherence if they had shorter disease duration, less bodily pain, and better self‐reported health and quality of life. A multivariate model (including disease duration, severity of bodily pain, self‐reported physical well‐being, the Frontal Assessment Battery, the Short Physical Performance Battery, and maximum walking time) explained 9% of the variance in exercise adherence, with shorter disease duration and less pain the strongest predictors (both predictors standardized β = −0.2; P = 0.04).
Conclusion
Disease duration and pain are likely to negatively influence exercise participation in people with PD. Given that most of the variance in adherence is unexplained, further work is required to determine other predictors of adherence to long‐term exercise programs.
The concept of ‘Devolution’—the transfer of powers away from the Central Government to more local bodies of Government, has been used across many different areas of policy and by many different ...national governments. This paper examines the devolution of transport powers to the existing Local Traffic Authorities in England via the 2004 Traffic Management Act. The paper first presents a summary of how several different nations have undertaken this process of devolving transport powers and responsibilities to either new or existing bodies. It then presents research from an electronic survey concerning how English Local Traffic Aut`horities are choosing to use some of the new powers available to them and their opinion on complementary areas of transport policy. Research is also presented from structured telephone interviews, concerning how individual Local Authorities perceive the efficacy and equity of the new legislation. Overall, the results show that only some of these new powers are likely to be used by English Local Authorities, with limited variation in how different types of LTA are choosing to implement these new powers. The structured telephone interviews provided some evidence that rural Authorities in particular are more dissatisfied with the legislation and consider some of the measures unhelpful. The results provide some insights on the formulation of devolved policy applicable to existing Local Government bodies and the varying benefits that can be perceived to apply to different types of Local Authority. Conclusions are drawn on some of the practical difficulties arising from the English experience, and lessons of relevance are drawn for other nations considering a similar devolution of transport powers.
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