Association Guidelines Research Articles

Calcitonin testing for detection of medullary thyroid cancer in people with thyroid nodules.

Thyroid nodules are very common in general medical practice, but rarely turn out to be a medullary thyroid carcinoma (MTC). Calcitonin is a sensitive tumour marker for the detection of MTC (basal calcitonin). Sometimes a stimulation test is used to improve specificity (stimulated calcitonin). Although the European Thyroid Association's guideline advocates calcitonin determination in people with thyroid nodules, the role of routine calcitonin testing in individuals with thyroid nodules is still questionable. The objective of this review was to determine the diagnostic accuracy of basal and/or stimulated calcitonin as a triage or add-on test for detection of MTC in people with thyroid nodules. We searched CENTRAL, MEDLINE, Embase and Web of Science from inception to June 2018. We included all retrospective and prospective cohort studies in which all participants with thyroid nodules had undergone determination of basal calcitonin levels (and stimulated calcitonin, if performed). Two review authors independently scanned all retrieved records. We extracted data using a standard data extraction form. We assessed risk of bias and applicability using the QUADAS-2 tool. Using the hierarchical summary receiver operating characteristic (HSROC) model, we estimated summary curves across different thresholds and also obtained summary estimates of sensitivity and specificity at a common threshold when possible. In 16 studies, we identified 72,368 participants with nodular thyroid disease in whom routinely calcitonin testing was performed. All included studies performed the calcitonin test as a triage test. Median prevalence of MTC was 0.32%. Sensitivity in these studies ranged between 83% and 100% and specificity ranged between 94% and 100%. An important limitation in 15 of the 16 studies (94%) was the absence of adequate reference standards and follow-up in calcitonin-negative participants. This resulted in a high risk of bias with regard to flow and timing in the methodological quality assessment. At the median specificity of 96.6% from the included studies, the estimated sensitivity (95% confidence interval (CI)) from the summary curve was 99.7% ( 68.8% to 100%). For the median prevalence of MTC of 0.23%, the positive predictive value (PPV) for basal calcitonin testing at a threshold of 10 pg/mL was 7.7% (4.9% to 12.1%). Summary estimates of sensitivity and specificity for the threshold of 10 pg/mL of basal calcitonin testing was 100% (95% CI 99.7 to 100) and 97.2% (95% CI 95.9 to 98.6), respectively. For combined basal and stimulated calcitonin testing, sensitivity ranged between 82% and 100% with specificity between 99% and 100%. The median specificity was 99.8% with an estimated sensitivity of 98.8% (95% CI 65.8 to 100) . Both basal and combined basal and stimulated calcitonin testing have a high sensitivity and specificity. However, this may be an overestimation due to high risk of bias in the use and choice of reference standard The value of routine testing in patients with thyroid nodules remains questionable, due to the low prevalence, which results in a low PPV of basal calcitonin testing. Whether routine calcitonin testing improves prognosis in MTC patients remains unclear.

Rates of underuse of statins among cancer survivors versus controls: NHANES 2011-2016.

Cardiovascular disease (CVD) is a major non-cancer cause of mortality among cancer survivors, and statin therapy is the mainstay of cardiovascular risk management. However, little is known about adherence to statin therapy relative to current guidelines for the management of cholesterol among cancer survivors. We investigated the prevalence of statin-eligible but untreated individuals among cancer survivors and factors associated with underuse of statins. We used US National Health and Nutrition Examination Survey data (2011-2016) and identified 706 cancer survivors and matched controls (1:2) by age and sex. We identified participants who met the American College of Cardiology/American Heart Association (2018) guidelines but were not currently in treatment. We estimated the proportion of patients who were statin-eligible but untreated and performed multivariable logistic regression analysis to identify the factors associated with underuse of statins. The mean age of the total sample was 62.2years (standard deviation, 9.1). Among the total participants, 37.5% of cancer survivors and 37.2% of controls were statin-eligible but untreated. The crude statin-eligible untreated proportion was 41.2% among cancer survivors who had received a cancer diagnosis within 3years and 40.3% among long-term survivors of 10years or more. In multivariate analysis, old age, male sex, lack of a usual source of care, current smoking, and low household income were significantly associated with statin-eligible untreated status. More than one-third of cancer survivors were statin-eligible but untreated under current guidelines. There is room for improvement to reduce the burden of non-cancer mortality by managing traditional cardiovascular risk factors.

A decade on from the publication of the British HIV Association's National HIV Testing Guidelines: are opportunities to increase the uptake of HIV testing still being missed?

Background: Guidelines recommend HIV testing in indicator conditions in which the prevalence of undiagnosed HIV exceeds 0.1%. We assessed adherence to national recommendations on HIV testing within the acute medical unit in NHS Fife. Secondly, we performed a look-back exercise to identify missed opportunities for HIV diagnosis in individuals who presented at a late stage of infection. Methods: Data were collected on admissions over a 24-hour-period during four consecutive weeks in 2018. Case records were reviewed and diagnoses were screened against a list of indicators. Additionally, data were obtained from HPS on late HIV diagnoses within NHS Fife from 2013-2018. Records were interrogated for presentations to healthcare services within the 5 years prior to HIV diagnosis. Results: In total, 226 patients were admitted during the study period. All patients were white, with median age 68yrs. 101 indicator conditions were identified, relating to 83 patients (36.7%). Bacterial pneumonia was the most frequently identified indicator (n=40). Only 3 patients were offered HIV testing (3.6%). From 2013-2018, 23 patients were diagnosed with HIV at late stage. The median age at diagnosis was 41yrs and the median CD4 count was 161 cells/mm3. Fifteen patients (65.2%) had presented to hospital in the 5 years preceding diagnosis with an indicator. The most frequently missed indicator was chronic diarrhoea (n=6). Three patients (13%) have died since diagnosis. Conclusions: * Opportunities to increase uptake of HIV testing among people who may have undiagnosed HIV are being missed * Further educational initiatives and review of local HIV testing protocols are indicated

Abstract WP427: Implementing an Algorithm Emphasizing Telestroke for Patients With an Acute Cerebrovascular Event in a Rural Setting

Background and Purpose: A stroke may occur without warning and deficits can range from mild deficits to death. Improved outcomes are associated with decreased time to revascularization of cerebral tissue. The time sensitive nature of stroke care contributes to the challenges associated with caring for individuals suffering from stroke who live far from a stroke center. The American Stroke Association (ASA) guidelines include a recommendation for the implementation of telestroke. The technology is preferred over telephone consults and is an effective method to determine eligibility of fibrinolytic therapy. Methods: The project was implemented in a stroke ready facility in a rural area and supported by an urban care center that is recognized as a comprehensive stroke center. Stroke education was provided to the rural site and an algorithm utilizing the telestroke technology was implemented. Times from door to CT (computed topography) scan, door to fibrinolytic therapy, and door to transfer time were tracked for 90 days to compare average times to baseline data using a one-tail t-test. Statistical significant was determined with a p-value <0.05. Results: There were 27 patients that presented during the collection period, with a baseline comparison of 39 patients over an 11-month period. Overall, each category had a decrease in time, with significant differences noted in door to CT and door to transfer time. The average door to CT time with telestroke decreased on average by 14.1 minutes from baseline data to a new average of 8.6 minutes. Door to transfer time with telestroke decreased by 42.2 minutes from baseline to a new average of 121.4 minutes. Additionally, during the collection period, fibrinolytic therapy initiation doubled, resulting in 48% receiving therapy. Due to the faster times, 35% of patients were able to receive a thrombectomy at the tertiary site. Conclusions: In conclusion, this study demonstrates promising results for the continuation of telestroke use in rural treatment sites for acute cerebrovascular events to decrease time to interventions for optimal outcomes.

Abstract WP245: New Definition of Hypertension and Incident Cerebral Microbleeds: A 7-Year Chinese Urban Community Study

Background and Purpose: Cerebral microbleeds (CMBs) are associated with recurrent stroke, dementia and mortality in the general population. Hypertension (blood pressure over 140/90 mmHg) was thought as a crucial risk factor of CMBs in the general population. However, the cutoff for diagnosis of hypertension was lowered to blood pressure over 130/80 mmHg in the 2017 American College of Cardiology / American Heart Association (ACC/AHA) guidelines. Whether the new definition of hypertension remains a potent risk factor of CMBs is questionable. We aimed to analyze the relationship between the new definition of hypertension and incident CMBs in a 7-year longitudinal community study. Methods: This study is part of the Shanghai Aging Study (SAS). 159 participants without stroke or dementia (mean age, 67.7 years) underwent repeated clinical examinations and cerebral MRI at baseline (2009-2011) and follow-up (2016-2018) with a median interval of 6.9 years. CMBs at baseline and follow-up were evaluated on T2*-GRE and SWAN sequence of MRI. We classified baseline blood pressure into four categories: normal BP, elevated systolic blood pressure, stage 1 hypertension and stage 2 hypertension according to the new criteria. We assessed the association of blood pressure categories with incident CMBs by generalized linear models. Results: Participants with incident CMBs had higher baseline systolic blood pressure (SBP) and pulse pressure (PP) than those without incident CMBs. The difference was significant in SBP (P=0.024), and marginally significant in PP (P=0.057). Both stage 1 and stage 2 hypertension were associated with a higher risk of incident CMBs (IRR=2.77, P=0.028; IRR=3.04, P=0.011, respectively). Conclusions: In this 7-year longitudinal study, participants with incident CMBs had higher SBP and PP at baseline. Stage 1 and stage 2 hypertension defined by this new criterion were associated with incident CMBs.

Concordance to Guideline-recommended Statin Therapy: Real-world Evidence from India

To evaluate concordance to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline on treatment of blood cholesterol for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in India. Concordance to 2013 ACC/AHA guideline was assessed by retrospectively analyzing statin therapy prescribing practice as per ASCVD risk score in four statin-benefit groups in 23,295 patients aged 40-79 years from health facilities across India between 2017 and 2018. Mean (±SD) age of patients was 58.9 (±9.2) years; 62% were men; 60% (n=14,070) had clinical ASCVD. Among patients without ASCVD (n=7,122), 3.9% (n=278) had low-density lipoprotein-cholesterol (LDL-C) ≥190 mg/dL, 94.0% (n=6,694) had diabetes mellitus and 2.1% (n=150) patients had 10-year ASCVD risk ≥7.5%. Among 18,795 patients (81%) eligible for high-intensity statins, only 34% were concordant whereas 63% were treated with moderate-intensity statins. Among 2,290 patients eligible for moderate-intensity statins, 76% were concordant and 18% received high-intensity statins. Among patients with ASCVD ( 7.5%, 83% remained under-treated. Most patients (82%) with LDL-C >190 mg/dL were prescribed with moderate-intensity statins. Most patients were receiving statins at dose non-concordant to 2013 ACC/AHA guideline, reflecting gaps in real-world practice of prescribing statins for primary and secondary prevention of ASCVD. Addressing care gaps and promoting compliance to optimize statin therapy will help reduce cardiovascular disease, especially in high-risk population among South Asians.

Improving the quality of CPR in the Community

An out of hospital cardiac arrest (OHCA) is defined as cessation of cardiac mechanical activity, confirmed by the absence of signs of circulation and that which occurs outside the hospital setting (Roger VL, 2011) About 70–85% of these events have a cardiac cause. Published literature identifies acute coronary syndrome (ACS) as the most frequent cause of OHCA, particularly among elderly and coronary vasospasm as a considerable cause among young healthy individuals. It can also occur from non-cardiac causes such as trauma, drowning, drug overdose, asphyxia, electrocution and primary respiratory arrests. (Sasson C, Kellermann AL. 2010). Early cardiopulmonary resuscitation (CPR), therapeutic hypothermia and early advanced care have a crucial role in management of OHCA. Every minute lost in initiating CPR leads to 10% decrease in survival rates of the victim (Go AS, Mozaffarian D-2013) since members of the community are the first to witness OHCA, there is an increasing recognition of the need to coordinate with the community in providing emergency medical care to optimize patient survival after an OHCA. American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care describes a “chain of survival” to reduce mortality and improve survival. The “chain of survival” comprises of five elements, namely, immediate recognition and rapid access, rapid CPR, rapid defibrillation, effective advanced care and integrated post cardiac arrest care. (Travers AH-: 2010)

The knowledge of undergraduate dental students and dentists about antibiotic prophylaxis in patients at risk for infective endocarditis

ABSTRACT Infective Endocarditis (IE) is an infection of the endocardial surface of the heart that is caused by fungi, bacteria or viruses. The high mortality and morbidity rates of IE have encouraged the adoption of preventive strategies. This study investigated the knowledge on the prevention of IE among 2nd, 3rd and 4th-year undergraduate dental students at the Escola Superior São Francisco de Assis (ESFA) and among dentists working in the municipality of Santa Teresa, ES, Brazil. Objective: The rationale for this study was to identify the gaps in their knowledge and raise awareness on the topic. Methods: The study was previously approved by the Research Ethics Committee. The sample consisted of dental students who had completed the Pharmacology for Dentistry course at the ESFA, totaling 35 2nd-year students, 29 3rd-year students, and 36 4th-year students. Thirty dentists registered in the Regional Council of Dentistry of Espírito Santo state, who were working in the municipality of Santa Teresa, ES, Brazil, were also included. All participants were given a questionnaire containing six objective and four subjective questions to assess their knowledge regarding the definition of IE, high-risk patients, dental procedures known to cause bacteremia, recommended dosage regimens for high risk patients, and additional care in the assistance of these patients. The questionnaires’ responses were reviewed following the American Heart Association (AHA) guidelines for disease prevention published in 2007. Results: The analysis of the results revealed a low rate of correct responses among students and dentists. The questions with the lowest rate of correct responses were those addressing the identification of patients at high risk for heart conditions and the dental procedures known to cause bacteremia, with no significant differences between the four groups analyzed (P > 0.05). Third-year dental students presented a frequency of correct responses significantly lower than that of the other groups (P < 0.001), which did not differ from each other. To conclude, all participants demonstrated poor knowledge about the topic, particularly 3rd-year dental students. Conclusion: These results reinforce the need for informative measures to raise awareness and improve the quality of dental care provided to the population.

Evidence summary of malnutrition risk screening in adult inpatients

Objective To assess and summary the guideline best evidence on malnutrition risk screening in adult inpatients so as to provide a reference for malnutrition risk screening of adult inpatients. Methods Guidelines on malnutrition risk screening in adult inpatients were systematically retrieved in nutrition association official website, guideline website and database and were screened. All of the guidelines were assessed by 4 trained researchers with the Appraisal of Guidelines for Research and Evaluation (AGREE Ⅱ) . Guidelines with level C were excluded, and guidelines with level A and B were selected to extract, translate and summary the recommendations. Results A total of 213 guidelines were retrieved and 140 were selected after eliminating repetitive guidelines. Finally, 13 guidelines were included after eliminating 128 guidelines by reading titles and abstracts. AGREE Ⅱ evaluation results showed that there were 3 guidelines with level A and 10 guidelines with level B. Analysis and summary showed that a total of 16 items of 3 classes best evidence on malnutrition risk screening in adult inpatients were selected including screening qualification, population, time and tools. Conclusions In this study, guidelines best evidence on malnutrition risk screening in adult inpatients provides a credible reference for clinical practice. Population with high risk of malnutrition should be assessed in comprehensive nutrition and should be treated in nutritional department when necessary. Key words: Malnutrition; Risk assessment; Guideline; Adult inpatients; Evidence summary; Recommendations

Continuous Cardiac Monitoring Policy Implementation: Three-year Sustained Decrease of Hospital Resource Utilization.

Inappropriate cardiac monitoring leads to increased hospital resource utilization and alarm fatigue, which is ultimately detrimental to patient safety. Our institution implemented a continuous cardiac monitoring (CCM) policy that focused on selective monitoring for patients based on the American Heart Association (AHA) guidelines. The primary goal of this study was to perform a three-year median follow-up review on the longitudinal impact of a selective CCM policy on usage rates, length of stay (LOS), and mortality rates across the medical center. A secondary goal was to determine the effect of smaller-scale interventions focused on reeducating the nursing population on the importance of cardiac alarms. A system-wide policy was developed at The Ohio State University in December 2013 based on guidelines for selective CCM in all patient populations. Patients were stratified into Critical Class I, II, and III with 72 hours, 48 hours, or 36 hours of CCM, respectively. Pre- and post-implementation measures included average cardiac monitoring days (CMD), emergency department (ED) boarding rate, mortality rates, and LOS. A 12-week evaluation period was analyzed prior to, directly after, and three years after implementation. There was an overall decrease of 53.5% CMDs directly after implementation of selective CCM. This had remained stable at the three-year follow-up with slight increase of 0.5% (p = 0.2764). Subsequent analysis by hospital type revealed that the largest and most stable reductions in CMD were in noncardiac hospitals. The cardiac hospital CMD reduction was stable for roughly one year, then dipped into a lower stable level for nine months, then returned to the previous post-implementation levels. This change coincided with a smaller intervention to further reduce CMD in the cardiac hospital. There was no significant change in mortality rates with a slight decrease of 3.1% at follow-up (p = 0.781). Furthermore, there was no significant difference in LOS with a slight increase of 1.1% on follow-up (p = 0.649). However, there was a significant increase in ED boarding rate of 7.7% (p < 0.001) likely due to other hospital factors altering boarding times. Implementing selective CCM decreases average cardiac monitoring rate without affecting LOS or overall mortality rate. Selective cardiac monitoring is also a sustainable way to decrease overall hospital resource utilization and more appropriately focus on patient care.

The need to accommodate monitor height changes between sitting and standing

Recently, the rate at which sit-to-stand workstations are being introduced into the workplace has seen a dramatic increase. Aside from adjusting the height of the desk when transitioning from sitting to standing, there is a lack of literature regarding the necessary adjustments to other equipment associated with the workstation. To better understand some of these limitations, 16 participants stood and sat at a sit-to-stand workstation while adhering to current Canadian Standards Association (CSA) Guidelines for Office Ergonomics. Transitioning between sitting and standing while adhering to CSA guidelines resulted in a 3.9 cm difference in monitor height relative to work surface between sitting and standing. Results from this investigation support the notion that monitor height adjustments relative to the work surface are necessary when utilising sit-to-stand workstations – with the implementation to practice message being that both sitting and standing configurations need to be assessed and accommodated in the workstation configuration. Practitioner summary: Limited guidelines exist in the necessary adjustments to equipment associated with sit-to-stand workstations. Transitioning between sitting and standing resulted in a 3.9 cm difference in monitor height relative to work surface between sitting and standing. This supports that monitor height adjustments relative to the workstation are necessary when using sit-to-stand workstations.

283Endovascular thrombectomy as a means to improve survival in acute ischemic stroke - A meta-analysis

Abstract Background and purpose Although endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) is guideline-recommended to improve functional recovery, thus far there are only inconclusive data from underpowered singular trials of EVT vs. medical therapy (MT) on mortality. We here aimed to perform a meta-analysis on short-term mortality in guideline-relevant EVT vs. MT randomized controlled trials (RCTs). Methods All randomized controlled trials (RCT) reporting EVT vs. MT in the latest 2018 American Stroke Association/American Heart Association (ASA/AHA) Guidelines were eligible for inclusion. Data were abstracted by two independent investigators and double-checked by four others. Study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% confidence intervals (CI). Ninety-day mortality and intracranial hemorrhage (ICH) were analyzed. Results Ten of the twelve guideline-relevant EVT vs. MT RCTs (DAWN, DEFUSE 3, ESCAPE, EXTEND-IA, MR CLEAN, MR RESCUE, REVASCAT, SWIFT PRIME, THERAPY, THRACE) with 2,313 patients were selected for inclusion. Studies IMS III and SYNTHESIS were excluded due to their very infrequent use of EVT. Stent retrievers (Trevo, Solitaire, Merci) were most frequently applied, followed by thrombus aspiration (Penumbra). Intravenous thrombolysis was administered in addition to EVT in the majority of patients. In the pooled meta-analysis of all eligible RCTs, EVT significantly reduced the risk for 90-day mortality by 3.7% compared to MT (15.0% vs. 18.7%; RR 0.81 with CI 0.68 to 0.98; p=0.03), accounting for a number-needed-to-treat of 27 to prevent one all-cause death. Trends were similar in early-window (RR 0.83) and late-window trials only (RR 0.76). There was no difference in the risk for ICH in EVT vs. MT (4.2% vs. 4.0%; RR 1.11 with CI 0.71 to 1.72; p=0.65). All included trials were published in high-quality journals and risk of bias was judged low. Conclusions This meta-analysis lends evidence to EVT benefits for survival already during the first 90 days after acute ischemic stroke. These results further highlight the evolution of interventional techniques in this setting.

P6365Contrasting the impact of the European (ESC/ESH 2018) versus American (ACC/AHA 2017) high blood pressure clinical practice guidelines in Poland

Abstract Background The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for the management of arterial hypertension and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults differ in approach to defining stages of hypertension and recommendations for treatment of high blood pressure. Purpose To contrast the implications of the ESC/ESH versus ACC/AHA hypertension guidelines among the general population in Poland – a country representing a high CVD risk region in Europe. Methods We used data from a representative random sample of 1439 Polish adults aged 40 to 79 from the research program NATPOL 2011. The analysis was weighted in order to reflect the structure of the population in Poland and was stratified by age and gender. We applied the ESC/ESH 10-year SCORE (Systematic COronary Risk Evaluation) and the ACC/AHA ASCVD (atherosclerotic CV disease) risk assessment tools and followed guideline-specific algorithms to detect hypertension and follow recommendations for treatment. Results The overall prevalence of hypertension among Polish adults according to the ACC/AHA guideline was 76.9% (95% CI, 74.7–79.0%) versus 51.8% (95% CI, 49.2–54.4%) according to the ESC/ESH guidelines. Application of the ACC/AHA guideline recommendations would result in antihypertensive drug treatment for 63.0% (95% CI, 60.5–65.5%) of Polish adults compared with 46.2% (95% CI, 43.6–48.7%) based on application of the ESC/ESH guidelines (difference 16.8% (95% CI, 14.9–18.8%), table 1). Table 1 2017 ACC/AHA guideline 2018 ESC/ESH guideline Δ (difference) Hypertension Recommended treatment Hypertension Recommended treatment Hypertension Recommended treatment % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Age 40–49 (n=391) 63.2 (58.4–68.0) 37.3 (32.6–42.1) 32.0 (27.4–36.6) 21.2 (17.2–25.3) 31.2 (26.6–35.8) 16.1 (12.5–19.8) 50–59 (n=452) 77.7 (73.8–81.5) 61.7 (57.2–66.2) 49.1 (44.5–53.7) 40.0 (35.5–44.6) 28.5 (24.4–32.7) 21.7 (17.9–25.5) 60–69 (n=356) 82.3 (78.3–86.3) 75.3 (70.8–79.8) 62.4 (57.3–67.4) 61.5 (56.5–66.6) 19.9 (15.8–24.1) 13.8 (10.2–17.3) 70–79 (n=231) 90.0 (86.2–93.9) 90.0 (86.2–93.9) 74.5 (68.8–80.1) 76.6 (71.2–82.1) 15.6 (10.9–20.3) 13.4 (9.0–17.8) Gender Male (n=689) 80.4 (77.4–83.4) 67.5 (64.0–71.0) 52.5 (48.8–56.3) 47.2 (43.4–50.9) 27.9 (24.5–31.2) 20.3 (17.3–23.3) Female (n=741) 73.6 (70.4–76.7) 58.8 (55.3–62.4) 51.2 (47.6–54.8) 45.2 (41.6–48.8) 22.4 (19.4–25.4) 13.6 (11.2–16.1) Conclusions Application of the ACC/AHA guideline would result in a considerable increase in the prevalence and antihypertensive drug treatment of hypertension in Polish adults compared with application of the ESC/ESH guidelines.

The SnapShot Freeze Algorithm Improves Image Quality of Coronary Computed Tomography Angiography Using High-Resolution Wide-Detector CT

Objective: The aim of this study was to investigate the effect the motion-correction reconstruction algorithm SnapShot Freeze (SSF) on the diagnostic performance of coronary computed tomography angiography (CCTA) using high-resolution, wide-detector CT. Methods: CCTA was performed using an electrocardiography-triggered auto-gating protocol in 62 patients. All images were reconstructed using both standard algorithm and motioncorrection algorithm (SSF). According to the American Heart Association (AHA) guidelines for coronary angiography, the coronary artery was divided into 15 segments. The coronary artery segments were evaluated using a 4-point Likert scale to determine the image quality. Arteries with a score greater than 1 were further evaluated by two expert radiologists blinded to conditions. The diagnostic performance of SSF was compared in the patients with high heart rate (HR ≥ 75 beats per minute) compared to low HR (&lt; 75 beats per minute). Results: At the segmental level, the Likert score for segments 1–4 and 6–14 were higher in SSF compared to standard algorithm (p &lt; 0.05). The proportion of images that was improved by SSF was greater for the high HR systolic phase imaging (66.7%) than for the low HR diastolic phase imaging (34.3%, p &lt; 0.05). Conclusion: The SSF algorithm improves coronary CTA images acquired using a 256-row wide detector CT, compared to standard algorithm, particularly in patients with high HR.

Potential ethical pitfalls and dilemmas in the promotion and use of American Psychological Association-recommended treatments for posttraumatic stress disorder.

A variety of potential unrecognized ethical concerns arise from the American Psychological Association's (APA, 2017) Clinical Practice Guideline for the Treatment of PTSD in Adults. In privileging short-term treatments that underscore symptom reduction as the predominant index of outcome, such as cognitive processing therapy and prolonged exposure, there is a susceptibility to mislead mental health professionals and clients alike to believe that lasting improvements in socioemotional well-being, and a time-intensive approach, are unrealistic, rather than realistic psychotherapy expectations. There are ethical implications to incompletely addressing clients' preferences and clinicians' judgments on matters such as preferred socioemotional outcomes, and desirable qualities in a therapist and therapy. As regard combat veterans, treating trauma-related guilt and shame as symptoms to be eliminated, rather than moral feelings to be acknowledged, expressed, and self-forgiven, warrants special ethical consideration. The high dropout rates of cognitive processing therapy and prolonged exposure raise questions as to whether their protocol-driven methods alienate substantial numbers of traumatized clients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Implications of the American Psychological Association’s posttraumatic stress disorder treatment guideline for trauma education and training.

There is a shortage of clinicians who have been trained in treating traumatized clients, despite the high prevalence of trauma exposure and its frequent link with psychopathology. To address this need, professional guidelines and resources have been developed, including a core set of trauma competencies that professionals must develop to provide trauma-informed services to clients and several treatment guidelines. We discuss The New Haven Competencies for Trauma Training and Practice, then review recently developed clinical and professional practice guidelines, with an emphasis on the American Psychological Association (APA)'s Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD; "APA PTSD Guideline"). The APA PTSD Guideline was developed to guide clinicians in treatment planning for traumatized clients. However, numerous concerns about the Guideline and its limitations have been raised, and we present those that are relevant to training students and professionals about treating traumatized clients. We consider whether the APA Guideline is consistent with current trauma training needs, models, initiatives, and resources. We conclude that students and professionals who apply the treatments identified by the APA PTSD Guideline as "strongly supported" by empirical evidence may inadvertently overwhelm some clients with complex trauma presentations, which could result in poor outcomes or even harm. Furthermore, the Guideline does not adequately address aspects of treatment that are crucial to training about trauma, such as considering the client's cultural and individual needs and clinician self-care. We suggest training methods that take into consideration the limitations of the APA PTSD Guideline. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trauma training: Competencies, initiatives, and resources.

Traumatic stress is currently not a required component of the standard curricula in graduate-level education in clinical and counseling psychology. However, due to the high prevalence of trauma and its potentially deleterious physical and mental health effects in the general and clinical populations, it is imperative that psychology graduate students and practitioners understand the relevance of trauma in their clients' lives and its impact in clinical research. A comprehensive model of trauma-focused empirically informed competencies (knowledge, skills, and attitudes) was developed at a national consensus conference in 2013 and approved by the American Psychological Association in 2015 as part of that organization's education and training policy. These trauma competencies predated the American Psychological Association's Posttraumatic Stress Disorder Guidelines, and provided consensus about the scientific, theoretical, ethical, and professional foundational knowledge, skills, and attitudes for all trauma-informed professional practice, not solely treatment. The two endeavors are related and potentially synergistic, but separate. Intended to guide training programs' curriculum development and psychologists' self-monitoring, the trauma competencies serve as aspirational goals for psychologists. Training issues in these and other trauma competencies are discussed. Perhaps, most importantly, the scientific literature on trauma is constantly evolving, and thus embracing an ever-evolving curriculum and lifelong-learning approach is essential. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The cultural context of trauma recovery: Considering the posttraumatic stress disorder practice guideline and intersectionality.

The American Psychological Association's (2017) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults endorsed by the American Psychological Association notes that attention to cultural context is a required component of trauma-informed mental health care provision. Despite the inclusion of this statement, the Treatment of PTSD Guideline does not give adequate attention to culture in the defining of trauma, review of the trauma literature, the criteria adopted for evaluation of PTSD treatments, and, resultantly, the determination of treatment recommendations. Culture plays a significant role in the vulnerability to, experience of, and recovery from mental health sources of distress, including interpersonal trauma (Bryant-Davis, 2005). Approaches to trauma-focused psychotherapy that are ethically sound call for a prioritizing of cultural competence (awareness, knowledge, and skills), as well as cultural humility (Harvey & Tammala-Nara, 2007). Trauma survivors, however, hold multiple identities simultaneously that influence their conceptualizations of trauma, therapy, and the recovery process (Brown, 2008). Intersectionality refers to the way in which a multiply marginalized person experiences cultural identity and oppression that is qualitatively different than the experience of trauma survivors from dominant cultural groups (Crenshaw, 2005). The realities of racism, sexism, heterosexism, and classism, as well as their influence on the trauma recovery process, are examined, while noting the minimal attention that has been given to additional forms of oppression such as religious intolerance and able-bodyism. This critical review of the literature will examine the theoretical and empirical literature, which has examined the framework and strategies that have been cultivated in service to trauma survivors who have been traditionally underserved. Attention will be given in particular to benefits, limitations, and critiques of evidence-based interventions, as well as benefits, limitations, and future research needs of both culturally modified interventions and culturally emergent trauma interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline.

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association's (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Guideline orthodoxy and resulting limitations of the American Psychological Association's Clinical Practice Guideline for the Treatment of PTSD in Adults.

This article introduces the special issue in which we explore problems and limitations inherent both in the development and implementation of the American Psychological Association's (APA) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults. As Chair (Christine A. Courtois) and member (Laura S. Brown) of the guideline development panel, we were in a unique position to observe how certain decisions made by the APA regarding how this guideline should be produced led to flaws in the final product. In this special issue, we address problems that may be inherent in many clinical practice guidelines for psychotherapists. Our authors explore the importance of a more ecologically-informed model for such guidelines, one that would take into account the body of research on the psychotherapy relationship, psychotherapy process, and a broad range of psychotherapy outcomes. We end with recommendations APA might take to generate future clinical practice guidelines that are well-founded in APA's own definitions of evidence-based practice, and more attuned to APA's increasing attention to the specialized concerns of clients who come from socially marginalized groups. (PsycINFO Database Record (c) 2019 APA, all rights reserved).