Search Results (200)

Background: Inappropriate antibiotic prescribing by dental practitioners is a significant problem in low- and middle-income settings, such as India, where there are no guidelines for dental prescribing. This study aims to report, in a step-by-step process, the co-development of a computer-based stewardship educational intervention with Indian stakeholders to reduce inappropriate antibiotic prescribing by primary care dental practitioners in India. Methods: The development process of our intervention was guided by the Medical Research Council framework for developing and evaluating complex interventions. In alignment with the framework’s core elements, a co-production research approach was employed. Engagement with local stakeholders, including primary care dental practitioners, academic dentists, and those from the Indian Dental Association, facilitated the development of a contextually appropriate intervention that was informed by a prior needs assessment (a systematic review and a policy document analysis conducted in India) and evidence from global literature. The intervention was refined through iterative feedback from stakeholders and pre-testing. Results: An educational antibiotic stewardship intervention was co-developed in collaboration with stakeholders from Chennai, a major city in southern India. The final intervention comprised three components: 1. A one-page chairside guide summarising common areas of dental antibiotic use for easy reference in clinical settings; 2. A training module based on the chairside guide; and 3. A patient information sheet to facilitate dentists’ communication with patients. The intervention components were designed to be clear, practical, and contextually relevant, with the potential to enhance clinical decision-making and promote evidence-based antibiotic prescribing practices. Conclusions: This research paper describes, in a structured manner, how an educational antibiotic stewardship intervention for dental practitioners in India was co-developed by researchers and local stakeholders. Further feasibility testing is required to address uncertainties identified at the conclusion of the development process, including those related to dentists’ perceptions of the intervention, the utility of the intervention tools, and prescription recording. Full article

Background: Electroencephalographic (EEG) neurofeedback training is gaining traction as a non-pharmacological treatment option for Parkinson’s disease (PD). This paper reports the first pre-registered, integrated systematic review and meta-analysis of studies examining the effects of EEG neurofeedback on cortical activity and motor function in people with PD. Method: We searched Cochrane Databases, PubMed, Embase, Scopus, Web of Science, PsycInfo, grey literature repositories, and trial registers for EEG neurofeedback studies in people with PD. We included randomized controlled trials, single-group experiments, and case studies. We assessed risk of bias using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies tools, and we used the Grading of Recommendations, Assessment, Development and Evaluations tool to assess certainty in the evidence and resultant interpretations. Random-effects meta-analyses were performed. Results: A total of 11 studies (143 participants; Hoehn and Yahr I–IV) met the criteria for inclusion. A first meta-analysis revealed that EEG activity is modified in the prescribed way by neurofeedback interventions. The effect size is large (SMD = 1.30, 95% CI = 0.50–2.10, p = 0.001). Certainty in the estimate is high. Despite successful cortical modulation, a subsequent meta-analysis revealed inconclusive effects of EEG neurofeedback on motor symptomology. The effect size is small (SMD = 0.10, 95% CI = −1.03–1.23, p = 0.86). Certainty in the estimates is low. Narrative evidence revealed that interventions are well-received and may yield specific benefits not detected by general symptomology reports. Conclusion: EEG neurofeedback successfully modulates cortical activity in people with PD, but downstream impacts on motor function remain unclear. The neuromodulatory potential of EEG neurofeedback in people with PD is encouraging. Additional well-powered and high-quality research into the effects of EEG neurofeedback in PD is warranted. Full article

Background: Adherence to Medical Nutrition Therapy (MNT) is a key determinant of therapy success, particularly in chronic diseases like chronic kidney disease (CKD). MNT in CKD requires significant changes in patient’s dietary habits, which can affect long-term adherence. This study aims to evaluate the adherence to MNT in stage 5 CKD patients undergoing conservative kidney management (CKM), identifying potential challenges and strengths of nutritional intervention. Methods: We enrolled in 94 stage 5 CKD patients undergoing CKM at the University Hospital of Modena, Italy. We collect clinical data from medical and nutrition records. The inclusion criteria comprised patients of all genders, ages, and ethnicity with stage 5 chronic kidney disease (CKD), in pre-dialysis, enrolled in the nephrology and dietetics program, who had access to 24-h urine tests, anthropometric measurements, and dietary history records. Exclusion criteria included patients with CKD stages lower than 5, those who had not undergone at least one nutritional assessment, or lacked accessible 24-h urine data. The study utilized medical and dietary records from September 2017 to March 2025. The primary outcome was the assessment of adherence to medical nutrition therapy (MNT), comparing prescribed protein intake with actual intake, estimated from dietary history (DH). Protein intake was compared with normalized protein nitrogen appearance (nPNA) as stated by recent guidelines. Additional factors influencing adherence, such as age, gender, comorbidities, physical activity, and prior dietary interventions, were also evaluated. Anthropometric measurements and biochemical tests were collected, and dietary intake was assessed using a seven-day DH. Results: Data were analyzed using descriptive statistics, linear correlation models, univariate logistic regression, t-tests, paired t-tests, and chi-square tests, with significance set at p < 0.05. Most of the patients follow suggested energy and protein intakes limits; however, substantial individual variability emerged Bland–Altman analysis indicated a moderate bias and wide limits of agreement for energy intake (+116 kcal; limits of agreement –518.8 to +751.3 kcal), revealing frequent overestimation in self-reports. Protein intake showed less systematic error, but discrepancies between dietary recall and biochemical markers persisted. Protein intake decreased significantly over time (p < 0.001), while correlation with nPNA did not reach statistical significance (ρ = 0.224, p = 0.051). No significant associations were identified between adherence and most clinical or lifestyle factors, although diabetes was significantly associated with lower adherence to protein intake (p = 0.042) and a predominantly sedentary lifestyle showed a borderline association with energy intake adherence (p = 0.076), warranting further investigation. Longitudinal analysis found stable BMI and body weight, alongside notable reductions in sodium (p = 0.018), potassium (p = 0.045), and phosphorus intake (p < 0.001) over time. Conclusions: Assessing dietary adherence in CKD remains complex due to inconsistencies between self-reported and biochemical estimates. These findings highlight the need for more objective dietary assessment tools and ongoing, tailored nutritional support. Multifaceted interventions—combining education, personalized planning, regular monitoring, and promotion of physical activity—are recommended to enhance adherence and improve clinical outcomes in this vulnerable population. Full article

Background: Poor adherence to antihypertensive therapy is a major barrier to effective blood pressure control, particularly in countries with a high burden of non-communicable diseases. In Kazakhstan, improving adherence is a key objective of the “Densaulyk” State Health Program (2020–2025). Objective: To assess medication adherence among patients with arterial hypertension in Kazakhstan and identify associated socio-demographic and clinical factors. Methods: A cross-sectional survey was conducted among outpatient hypertensive patients at a major urban medical center. Adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Socio-demographic characteristics, disease duration, and the number of prescribed medications were analyzed in relation to adherence levels. Results: Adherence was significantly associated with age, ethnicity, education, marital and financial status, disease duration, and treatment complexity. A notable share of participants demonstrated low to moderate adherence. The use of self-reported data may have introduced bias. Conclusions: Medication adherence in Kazakhstan is influenced by multiple interrelated factors. Targeted and culturally appropriate interventions—such as simplified regimens, digital tools, and broader access to subsidized drugs—are essential to improve long-term outcomes in hypertension management. Full article

Background: Opioids are commonly used to manage both acute and chronic pain by acting on opioid receptors in the central and peripheral nervous systems. However, concerns about their increasing prescription and misuse have emerged due to adverse effects, toxicity, and the global impact of opioid-related harm. Objectives: This systematic review aims to evaluate the harmful (adverse and toxic) effects of prescribed opioids on the pediatric and the general population. Methods: Following PRISMA guidelines, a systematic search was conducted for data from January 2011 to December 2024 across selected electronic databases (PubMed^®, SciELO^®, Web of Science^®, and EMBASE^®) using a specific search strategy with Boolean operators. Cross-sectional, cohort, and case–control designs published in English, analyzing and identifying the harmful effects of prescribed opioids in children and the general population, were eligible for inclusion. Three reviewers independently assessed titles and abstracts for eligibility, followed by a full-text review. A referee reviewer resolved discrepancies. Data extraction was performed for qualifying studies. The risk of bias was assessed by the ROBINS-I tool. Results: A total of 3984 papers were collected, with 1697 duplicates and 2062 non-eligible papers removed; resulting in 25 papers (112.825 patients) selected for qualitative analysis. The pediatric group experienced more harmful effects across multiple body systems (nausea and vomiting, hypotension, agitation, drowsiness/lethargy, lethargy, respiratory depression, aspiration pneumonia) compared to the general population (dominant S wave, long QTc interval, right axis deviation, seizure). Conclusions: Despite the data heterogeneity, this study highlights the importance of evaluating the harmful effects of opioids, particularly in pediatric patients, to assess the risk–benefit balance and health risks associated with their use. The lower number of effects in the general population may be attributed to increased pharmacological tolerance and tolerability. Full article

Background/Objectives: Clear aligners are increasingly prescribed for orthodontic treatment, primarily in adult patients; however, concerns have been raised that this treatment approach may negatively impact root length, especially in endodontically treated teeth. The present investigation aims to systematically synthesize available research addressing the potential effects of clear aligner orthodontic treatment on root length changes in endodontically treated teeth. Methods: Four electronic databases were searched until May 2025, and lists of references from relevant publications were screened to identify studies (randomized clinical trials, controlled clinical trials, and observational studies) written in the English language with no date restriction. Clinical studies comparing clear aligner orthodontic treatment in endodontically treated teeth versus vital pulp teeth in humans, using cone beam computed tomography or panoramic radiographs to evaluate root resorption, were assessed. Following study selection and data extraction, the risk-of-bias assessment was evaluated with the Newcastle–Ottawa tool for the observational studies. Results: A total of 173 studies were retrieved, and ultimately 2 observational cohort studies were included in the systematic review, encompassing 135 patients (69.6% female; with an average age of 22.5 years). The present review found an association between endodontic status and root resorption, with vital pulp teeth (VPT) exhibiting a greater degree of resorption compared to root canal treated teeth (RCT). Clear aligner (CA) orthodontic treatment resulted in less root resorption than fixed orthodontic appliances (FAs). Conclusions: Limited evidence indicates that clear aligner orthodontic treatment leads to a lower occurrence of root resorption and fewer cases of severe root resorption in endodontically treated teeth. Based on findings from studies comparing CAs to FAs, there is overall significantly greater resistance to root resorption in RCT than VPT, irrespective of the orthodontic treatment modality (CAs or FAs). Full article

Background: Smoking is one of the leading causes of preventable mortality worldwide. Smoking cessation treatments require personalized therapeutic approaches. Artificial intelligence (AI) is increasingly utilized in clinical decision support systems; however, its role in smoking cessation treatment remains underexplored. This study aims to evaluate the concordance between ChatGPT-4.0-generated treatment recommendations and physician decisions in smoking cessation therapy. Methods: This retrospective and descriptive study was conducted by reviewing the electronic records of patients who presented to a Smoking Cessation Clinic. The ChatGPT-4.0 model was used to compare AI-generated treatment recommendations with physician-prescribed therapies. Concordance rates and the quality of AI-generated information (inappropriate, useful, or perfect information) were assessed. Statistical analyses were performed using SPSS 25.0. Results: A total of 82 patient records were analyzed. The mean age was 40.71 ± 12.87 years (range: 19–69). The overall concordance rate between physicians and ChatGPT-4.0 was 67.1%. Regarding ChatGPT-4.0-generated information quality, 32.9% of cases received inappropriate recommendations, 36.6% received useful recommendations, and 30.5% received optimal recommendations. ChatGPT-4.0 provided inappropriate recommendations in 81.5% of cases involving chronic diseases and 77.8% of cases involving regular medication use (p = 0.021, p = 0.030, respectively). ChatGPT-4.0 achieved the highest rate of optimal recommendations (52.0%) for cytisine therapy. Conclusions: ChatGPT-4.0 can serve as a supportive tool in smoking cessation treatment. However, it remains insufficient in managing complex clinical cases, emphasizing the necessity of physician oversight in final decision-making. Enhancing AI models with larger and more diverse datasets may improve the accuracy of treatment recommendations. Full article

Background: Therapeutic exercise (TE) is recommended as the first line of treatment for low back pain (LBP), but questions remain about the true efficacy of TE in the acute phase. This study aimed to evaluate the effectiveness of isolated TE in reducing pain intensity and disability in patients with acute or subacute LBP. Methods: A systematic review with meta-analysis was conducted following the PRISMA guidelines. Randomized controlled trials (RCTs) that analyzed therapeutic exercise alone in one of the intervention groups and assessed pain intensity and disability were included; both outcomes were considered primary in this review. The quality of evidence was assessed using the GRADE tool. Results: Five RCTs were included. Meta-analyses were performed in subgroups according to the comparators: usual care, education, manual therapy, and bed rest. Statistically significant differences in favor of TE were found only when compared to usual care (SMD = −0.23; 95% CI [−0.45, −0.01]; p = 0.04). Conclusions: TE, when prescribed as an isolated intervention, appears to be more effective than usual care in improving short-term disability outcomes in patients with acute LBP. However, the limited quality and number of available studies, together with the typically favorable natural course of acute LBP, suggest that these findings should be interpreted with caution. Current evidence supports the integration of exercise within a comprehensive, multimodal management plan that addresses the physical, psychological, and social dimensions of pain. Full article

Proton pump inhibitors (PPIs) are among the most prescribed drugs worldwide owing to their proven efficacy in symptom control and mucosal healing for acid-related disorders including gastroesophageal reflux disease (GORD), peptic ulcer disease, Helicobacter pylori eradication, functional dyspepsia, and gastroprotection in high-risk patients. However, long-term use beyond approved indications is increasingly common and has raised safety concerns. Observational studies link chronic PPI use to a myriad of adverse outcomes such as enteric infections (e.g., Clostridioides difficile), nutrient deficiencies (magnesium, vitamin B12), osteoporotic fractures, chronic kidney disease, dementia, and gastric and colorectal cancer. While causality is not always established, these associations warrant cautious risk–benefit assessment in patients receiving prolonged therapy. Current guidelines advocate periodic review of ongoing PPI use and emphasise deprescribing where appropriate. Strategies include dose reduction, on-demand or intermittent use, and switching to H2-receptor antagonists, particularly in patients with non-erosive reflux disease or functional dyspepsia. Tools from the National Institute for Health and Clinical Excellence, American College of Gastroenterology, and the Canadian Deprescribing Network assist clinicians in identifying candidates for tapering or discontinuation. This narrative review focuses on the concept of “PPI stewardship” by providing an evidence-based overview of PPI indications, risks, and deprescribing strategies to promote appropriate, safer, and patient-centred use of acid-suppressive therapy. Full article

Background and Objectives: Statins are among the most prescribed medications globally, primarily due to their potent lipid-lowering capabilities. This systematic review aims to identify, synthesize and evaluate current evidence regarding the potential protective effects of statins on sepsis mortality. Materials and Methods: A thorough and comprehensive database search was conducted in PubMed and Cochrane Library until 30 January 2025. Randomized control trials (RCTs) and cohort studies evaluating the effect of statin use on sepsis mortality were included. Risk-ratios (RRs) and 95% confidence intervals (CIs) were calculated. Statistical analysis and forest plot generation were performed using RevMan 5.4. Risk of bias was assessed using the RoB-2 and NOS tools. Results: A total of 49 studies were identified following application of the PRISMA guidelines. Of these, 16 studies were RCTs and 33 were cohort studies. The pooled analysis of RCTs demonstrated a non-significant 10% reduction in mortality in statin users (RR: 0.90, 95% CI 0.80–1.01). The pooled analysis of cohort studies showed that statin users have a 21% significantly reduced mortality risk (RR: 0.79, 95% CI 0.72–0.86). For the de novo statin users vs non-statin users, pooled analysis demonstrated a significant 25% reduction in mortality (RR: 0.75, 95% CI 0.69–0.81). The pooled analysis for the continuation of prior statin use vs discontinuation of statin use indicated 52% lower mortality in statin users who continued the use of statins (RR: 0.48, 95% CI 0.25–0.92). The pooled analysis of prior statin use and continuation of statins vs non-statin use revealed a significant 23% lower risk in statin users compared with non-statin users (RR: 0.77, 95% CI 0.69–086). Conclusions: According to our findings, statin use among septic patients is associated with a reduction in mortality, suggesting that statins may offer a beneficial therapeutic effect in the clinical setting. Clinicians may consider the continuation or potential incorporation of statin use as an additional regimen in the treatment of septic patients. Full article

Background: Adherence of renal patients to a prescribed therapeutic regimen is crucial for the success of haemodialysis and the decreased mortality rates of patients; however, 60% are non-adherent to dialysis, fluid, and dietary allowances. To identify promising interventions aimed at improving treatment adherence, this review aimed to collate research evidence on the prevalence of non-adherence to treatment (fluid, diet, and routine haemodialysis) and to synthesise the factors contributing to non-adherence in long-term haemodialysis patients. Methods: An integrative review was conducted using Whittemore and Knafl’s five-stage framework (2005). ProQuest, CINAHL, PubMed, and Web of Science were searched, using the keywords ‘haemodialysis’ and ‘non-adherence’. The review included peer-reviewed quantitative studies published in English from 1 August 2018 to 30 June 2025, focusing on adults over 18 undergoing haemodialysis. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was used to assess the quality of the studies. Results: Twenty-nine studies were included, identifying factors across four treatment groups: non-adherence to fluid allowance, dietary allowance, haemodialysis session, and fluid/diet/haemodialysis. These factors were grouped into three themes: social demographics, clinical factors, self-management, and perceptions. Commonly cited factors included age, gender, educational status, health literacy, and perception. Conclusions: This review highlights the complex factors influencing treatment non-adherence, which may vary based on the variables and measurement tools used in each study. Low-level health literacy is the most frequently cited modifiable factor. Therefore, prioritising effective patient education that enhances knowledge and understanding of the importance of adhering to treatment is key to improving compliance in long-term haemodialysis patients. Full article

Polypharmacy in older adults increases risks of adverse drug reactions (ADRs), hospitalisations, and mortality. Pharmacist-led interventions using validated tools (e.g., STOPP/START, MAI, STOPPFrail) aim to optimise prescribing, yet their impact on clinical and economic outcomes in UK/Ireland health systems remains underexplored. This systematic review aimed to critically assess the impact of pharmacist-led deprescribing interventions on PIP, clinical outcomes, and costs in older adults (≥65 years) across the UK and Ireland. Following PRISMA 2020 guidelines, four databases (PubMed, Scopus, Web of Science, Cochrane Library) were searched for studies (2010–2024). Eligible studies included randomised trials, observational designs, and intervention studies in hospitals, care homes, community pharmacies, and intermediate care settings. Fourteen studies met the inclusion criteria. The risk of bias was assessed using CASP checklists. Narrative syntheses and heat maps summarised the findings. Twelve of fourteen studies reported positive outcomes: reductions in potentially inappropriate medications, ADRs, medication burdens, and falls/fall risks. Medication appropriateness improved significantly in 35% of studies using the MAI. STOPPFrail reduced PIMs in care homes, while the MAI enhanced complex hospital reviews. Community interventions improved adherence and reduced the use of fall risk drugs. No studies demonstrated a reduction in hospitalisations, mortality, or the length of stays. Economic analyses showed mixed cost-effectiveness. Key barriers included low uptake of pharmacist recommendations and short follow-up periods. Pharmacist-led interventions have significantly improved the prescribing quality and reduced medication-related risks, but they fail to impact hospitalisations or mortality due to implementation gaps. Context-specific tools and policy reforms—including expanded pharmacist roles and electronic decision support—are critical for sustainability. Future research should focus on long-term outcomes, cost-effectiveness, and multidisciplinary integration. Full article

The use of opioids for cancer-related pain is essential but poses significant challenges due to the risk of misuse and the development of opioid use disorder (OUD). This review takes a multidisciplinary perspective based on the current scientific literature to analyze the pharmacological mechanisms, classification, and therapeutic roles of opioids in oncology. Key risk factors for opioid misuse—including psychiatric comorbidities, prior substance use, and insufficient clinical monitoring—are discussed in conjunction with validated tools for pain assessment and international guidelines. The review emphasizes the importance of integrating toxicological, pharmacological, physiological, and public health perspectives to promote rational opioid use. Pharmacogenetic variability is explored as a determinant of treatment response and addiction risk, underscoring the value of personalized medicine. Evidence-based strategies such as early screening, psychosocial interventions, and the use of buprenorphine-naloxone are presented as effective measures for managing OUD in cancer patients. Ultimately, this work advocates for safe, patient-centered opioid prescribing practices that ensure effective pain relief without compromising safety or quality of life. Full article

Background and objectives: Life expectancies have increased globally, including in Romania, leading to an aging population and thus increasing the burden of chronic diseases. Over 80% of individuals over 65 have more than three chronic conditions, with many exceeding ten and often requiring multiple medications and supplements. This widespread polypharmacy raises concerns about drug interactions, side effects, and inappropriate prescribing. This review examines the impact of polypharmacy in older adult patients, focusing on the physiological changes affecting drug metabolism and the potential risks associated with excessive medication use. Special attention is given to proton pump inhibitors (PPIs), a commonly prescribed drug class with significant benefits but also risks when misused. The aging process alters drug absorption and metabolism, necessitating careful prescription evaluation. Methods: We conducted literature research on polypharmacy and PPIs usage in the older adult population and the risk associated with this practice, synthesizing 217 articles within this narrative review. Results: The overuse of medications, including PPIs, may lead to adverse effects and increased health risks. Clinical tools such as the Beers criteria, the STOPP/START Criteria, and the FORTA list offer structured guidance for optimizing pharmacological treatments while minimizing harm. Despite PPIs’ well-documented safety and efficacy, inappropriate long-term use has raised concerns in the medical community. Efforts are being made internationally to regulate their consumption and reduce the associated risks. Conclusions: Physicians across all specialties must assess the risk–benefit balance when prescribing medications to older adult patients. A personalized treatment approach, supported by evidence-based prescribing tools, is essential to ensure safe and effective pharmacotherapy. Addressing inappropriate PPI use is a priority to prevent potential health complications. Full article

Phosphodiesterase type 5 (PDE5) inhibitors, including sildenafil, tadalafil, and vardenafil, are primarily prescribed for erectile dysfunction and pulmonary hypertension. Emerging evidence suggests they may also modulate inflammatory pathways and improve vascular function, but their effects on inflammatory biomarkers in humans remain incompletely defined. A systematic review and meta-analysis were conducted to evaluate the impact of PDE5 inhibitors on inflammatory and endothelial markers in adult humans. Randomized controlled trials comparing PDE5 inhibition to placebo were identified through electronic database searches. Outcomes included pro-inflammatory markers (TNF-α, IL-6, IL-8, CRP, VCAM-1, ICAM-1, P-selectin) and anti-inflammatory or signalling markers (IL-10, NO, cGMP), assessed at short-term (≤1 week), intermediate-term (4–6 weeks), or long-term (≥12 weeks) follow-up. Risk of bias was assessed using the Cochrane RoB 2 tool. A total of 20 studies comprising 1549 participants were included. Meta-analyses showed no significant short-term effects of PDE5 inhibition on TNF-α, IL-6, or CRP. Long-term treatment was associated with reduced IL-6 (SMD = −0.64, p = 0.002) and P-selectin (SMD = −0.57, p = 0.02), and increased cGMP (SMD = 0.87, p = 0.0003). Effects on IL-10 and nitric oxide were inconsistent across studies. Most trials had low risk of bias. PDE5 inhibitors may exert anti-inflammatory effects in long-term use by reducing vascular inflammation and enhancing cGMP signalling. These findings support further investigation of PDE5 in chronic inflammatory conditions. Full article