Clear Treatment Plan Research Articles

Correlation Between Magnetic Resonance Imaging Findings and Advanced Practice Physiotherapists' Assessment Findings in Diagnosing Lumbosacral Radiculopathy, and the Impact of Imaging Findings on Treatment Plans: A Retrospective Clinical Audit.

Magnetic Resonance Imaging (MRI) is increasingly used by Advanced Practice Physiotherapists (APPs) to confirm the diagnosis of lumbosacral radiculopathy (LSR) and to exclude other spinal pathologies. There is evidence of correlation between Advanced Practice Physiotherapists' diagnosis of lumbosacral radiculopathy and positive MRI findings, but there is limited evidence regarding the correlation between the full physiotherapy assessment and MRI findings. There are also conflicting evidence regarding the effect of MRI findings on treatment planning post-imaging. This study aims to examine the extent to which Advanced Practice Physiotherapists' diagnoses of lumbosacral radiculopathy correlate with those made after MRI, and to examine Advanced Practice Physiotherapists use of the local MRI referral pathway with respect to treatment plans, including testing correlation between pre-and post-MRI treatment plans. A cross-sectional, multi-centre, retrospective audit was conducted on 482 patients (276 female, 206 male) referred for lumbosacral MRI between January 2018 and December 2019. Non-linear regression analysis was performed to examine the relationships between diagnosis and treatment plans in LSR before and after MRI. The results show a significant positive correlation (p<0.001; R=0.196) between pre- and post-MRI diagnoses of lumbosacral radiculopathy. There was a significant positive correlation between pre- and post-MRI treatment plans for LSR (p=0.001; R=0.159). On comparison of pre- and post-MRI diagnoses of LSR, there is a weak positive correlation with high statistical significance (p<0.001; R=0.196). Reliability, tested using the intraclass correlation coefficient (ICC) across the four categories, was (p=0.041; R=0.033). This shows a weak positive correlation with statistical significance. Advanced Practice Physiotherapists can confidently diagnose and treat lumbosacral radiculopathy following initial assessment, although a minority of referrals lack a clear or appropriate treatment plan.

Patients’ and caregivers’ perspectives of the atopic dermatitis journey

Background Understanding the patient journey is important to optimize care for patients with atopic dermatitis (AD) and overcome challenges in diagnosis and management. Objective To explore patient and caregiver perspectives regarding their experience with AD. Methods Patients and caregivers of patients with AD completed a pre-meeting survey and were invited to join an advisory board meeting in their country (China, Hong Kong, Ireland, Japan and Lebanon) to discuss the survey results. Data were analyzed descriptively. Results The survey included 31 participants (patients and caregivers) from Hong Kong (n = 7), China (n = 7), Ireland (n = 6), Japan (n = 6) and Lebanon (n = 5). The most challenging factors in the AD journey were management of symptoms before a confirmed diagnosis (68%), sudden recurrence of flares or worsening of symptoms (68%) and lifestyle changes (52%). In terms of overall AD management, 35% of participants indicated that AD was managed well, 23% had a clear treatment plan and 19% were generally satisfied with disease management. A collaborative relationship with healthcare professionals was favored. Conclusion A holistic assessment of AD includes understanding patient and caregiver preferences, needs, experiences and disease perceptions. Addressing the identified gaps may improve the management of AD.

Radical cystectomy or trimodality therapy for muscle-invasive bladder cancer: a qualitative study exploring patient priorities and counselling needs when making a treatment choice

BackgroundThis study aims to explore the priorities and counselling needs of patients with muscle-invasive bladder cancer faced with a decision between radical cystectomy and trimodality therapy.MethodsWe performed a qualitative study according to the phenomenological approach. Sixteen muscle-invasive bladder cancer survivors who underwent radical cystectomy or trimodality therapy completed a semi-structured interview between May 2022 and February 2023. Patients were recruited via Ghent University Hospital and a patient organisation. Data were analysed with inductive thematic analysis by a multi-disciplinary team using an iterative approach and investigators’ triangulation.ResultsFour main priorities determining the treatment decision were identified. (1) curing the disease; (2) health-related quality of life (physical, mental and social); (3) confidence in the treatment, which was mainly based on trust in the clinician; and (4) personal attributes. Trust in the clinician can be achieved by fulfilling the patient’s information needs (accurate, complete, clear, impartial, personalised, realistic, and transparent information), ensuring accessibility of the clinician, and creating a clear and personalised treatment plan, involving patients to the extend they desire. Many patients considered a patient decision aid as a valuable asset in this process.ConclusionPriorities vary between patients with muscle-invasive bladder cancer. Identifying individual priorities and offering personalised information about them is crucial for ensuring trust in the clinician and confidence in the treatment. Use of a patient decision aid can be beneficial in this process.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

The HDAT Helper - Developing an Online Tool to Improve the Safety and Accuracy of Antipsychotic Prescribing

AimsHigh Dose Antipsychotic Therapy (HDAT) prescriptions and combinations of antipsychotic agents are not currently recommended as standard practice by the RCPsych. College guidance (RCPsych, CR 190) advises that there is “little convincing evidence that off-label prescription of doses of antipsychotic medication above the licensed dosage range has any therapeutic advantage in any clinical setting” and that “any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target”. Despite this, both national and local data demonstrate that HDAT has continued to be used regularly across psychiatric inpatient settings, often out of hours and often secondary to the use of PRN Antipsychotics, without a clear treatment plan or rationale. My aim was to create a simple, accessible, online tool that would allow prescribers to quickly and efficiently calculate the BNF percentage of any antipsychotic prescription and that this will enable safer prescribing.MethodsWith the support of a web-developer, I developed an online tool quickly and easily calculate antipsychotic BNF percentages. The tool can be found here: www.hdat.co.ukResultsThe HDAT Helper has been well received at local presentations and I have recently gained the support of senior management at Southern Health NHS Foundation Trust to develop an education programme on HDAT and the HDAT Helper to expand use of the tool across Southern Health.ConclusionThe current expert guidance, clinical research and my own audit work demonstrates that there are ongoing issues with the prescription of high dose antipsychotics and that at times this occurs inadvertently when different agents are combined.I believe that the HDAT Helper can make prescribing of antipsychotic agents clearer and more efficient and as a result significantly improve patient safety.

Expert consensus on ensartinib in the treatment of anaplastic lymphoma kinase-positive non-small cell lung cancer

The mutation rate of anaplastic lymphoma kinase (ALK) in patients with non-small cell lung cancer is 3% to 7%. Due to its low mutation rate and better long-term survival compared with epidermal growth factor receptor-positive non-small cell lung cancer patients, therefore, it's called "diamond mutation". At present, there are three generations of ALK tyrosine kinase inhibitor (TKI) drugs in the world. The first-generation ALK-TKI drug approved in China is crizotinib, and the second-generation drugs are alectinib, ceritinib and ensartinib. Among them, ensartinib is an ALK-TKI domestically developed, and its efficacy is similar to that of alectinib. The main adverse event is transient rash, and compliance to ensartinib is better from the perspective of long-term survival of patients. The manifestation of rash caused by ensartinib is different from that of other ALK-TKI drugs. In order to facilitate clinical application and provide patients with more treatment options, under the guidance of the Committee of Cancer Rehabilitation and Palliative Care of China Anti-Cancer Association, this article collects and summarizes the common adverse reactions of ensartinib. Based on the clinical practice, a clear adverse classification and specific treatment plan are formulated, in order to provide a corresponding reference for clinicians to make more comprehensive clinical decisions.

Moral Distress and Moral Injury Among Attending Neurosurgeons: A National Survey.

"Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

A Role of IL-17 in Rheumatoid Arthritis Patients Complicated With Atherosclerosis.

Rheumatoid arthritis (RA) is mainly caused by joint inflammation. RA significantly increases the probability of cardiovascular disease. Although the progress of RA has been well controlled recently, the mortality of patients with RA complicated with cardiovascular disease is 1.5–3 times higher than that of patients with RA alone. The number of people with atherosclerosis in patients with RA is much higher than that in the general population, and atherosclerotic lesions develop more rapidly in patients with RA, which has become one of the primary factors resulting in the death of patients with RA. The rapid development of atherosclerosis in RA is induced by inflammation-related factors. Recent studies have reported that the expression of IL-17 is significantly upregulated in patients with RA and atherosclerosis. Simultaneously, there is evidence that IL-17 can regulate the proliferation, migration, and apoptosis of vascular endothelial cells and vascular smooth muscle cells through various ways and promote the secretion of several cytokines leading to the occurrence and development of atherosclerosis. Presently, there is no clear prevention or treatment plan for atherosclerosis in patients with RA. Therefore, this paper explores the mechanism of IL-17 in RA complicated with atherosclerosis and shows the reasons for the high incidence of atherosclerosis in patients with RA. It is hoped that the occurrence and development of atherosclerosis in patients with RA can be diagnosed or prevented in time in the early stage of lesions, and the prevention and treatment of cardiovascular complications in patients with RA can be enhanced to reduce mortality.

NPR2 gene variants in familial short stature: a single-center study.

NPR2 variants are associated with various short stature and bone dysplasia, such as acromesomelic dysplasia Maroteaux tyoe, individuals with a phenotype similar to Léri-Weill syndrome (LWD), and idiopathic short stature (ISS). However, few studies have reported on the relationship between familial short stature (FSS) and NPR2 variants. This study aimed to explore the relationship between FSS and NPR2 variants through the detection and identification of NPR2 variants in children with FSS, phenotypic description, clear treatment plan, and follow-up of treatment effect. Children who met the FSS diagnostic criteria and had informed consent were included in the study. The trio whole-exome sequencing method (trio-WES) was used to detect and evaluate the NPR2 variants. A total of 16 children with short stature were included in this study (pretreatment height≤-2 standard deviation (SD) in both the patient and the shorter parent, unknown genetic etiology). NPR2 variants were identified in 12.5%(2/16) of the participants. Patient A was a 6-year-old male and 103.7cm tall (-3.11SD), while Patient B was a 9-year-old female and 123.2cm tall (-1.88SD). However, their heights increased after recombinant human growth hormone (rhGH) treatment. The height of patient A increased by 0.36SD six months after treatment while that of patient B increased by 1.22SD after one and a half years of treatment. NPR2 variant causes FSS. The growth rate of children significantly improved after rhGH treatment. However, further follow-up study is needed to determine the final height after long-term treatment.

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology.

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ©RSNA, 2021.

Improving the patient's experience in the emergency department during COVID-19 pandemic: a community-based analysis from Western Saudi Arabia.

Background Patient satisfaction is an important measure of the health care encounter. It is challenging to achieve a perfect patient experience during the current COVID-19 pandemic, especially from an emergency department visit. Aim This study aimed to assess the factors that improve patient experience during an emergency department (ED) visit in the western region of Saudi Arabia. Methods This is a cross-sectional study, conducted over a month from January to February 2021. Via an electronic survey tool, we used the de en (EQS-H) to measure patients’ satisfaction with their ED encounter. Results The total level of satisfaction was high in 43.66% (n=224) of participants, moderate in 37.04% (n=190), and 19.29% (n=99) were unsatisfied. We noted significant predictors of dissatisfaction, including increasing age, higher educational level, and the existence of chronic diseases. A clear treatment plan and discharge instructions were important determinants for improving patient satisfaction. Conclusion The determinants of patient satisfaction during an ED visit are an important quality marker of the emergency department encounter. Such findings should be used as a benchmark for future programs aiming to improve patients’ experience during ED visits.

The effect of surgery plus intensity-modulated radiotherapy on treatment in laryngeal cancer: A clinical retrospective study.

As a common head and neck tumor, laryngeal cancer has attracted heightened attention for its treatment and prognosis. Surgery and radiotherapy were mainly therapeutic approaches in laryngeal cancer, and intensity-modulated radiotherapy (IMRT) was a precision treatment way in radiotherapy. However, the therapeutic effect of surgery plus IMRT in laryngeal cancer was rarely reported. This study aims to determine the effect of IMRT on the treatment of patients with laryngeal cancer. A total of 125 patients with laryngeal cancer were collected and retrospectively analyzed based on their clinical data and follow-up results. These patients had a clear treatment plan for surgery and intensity-modulated radiotherapy. Smoking, lymph node metastasis, TNM staging and therapeutic approaches could affect the survival of patients with laryngeal cancer. It was shown that the laryngeal function retention rate in the simple IMRT group was significantly higher than the simple surgery group and surgery plus IMRT group. The 5-year survival rate of surgery plus IMRT, simple surgery and simple IMRT were 82.86%, 53.85% and 43.33%, respectively. The locoregional recurrences rate of surgery plus IMRT, simple surgery and simple IMRT were 14.29%, 34.62% and 43.33%. Surgery plus IMRT was a feasible and efficacious treatment technique for patients with laryngeal cancer, which effectively prolong the survival time of patients.

Therapeutic and Preventive Approaches against COVID-19: A Review

Several vaccines are found for the novel coronavirus SARS-CoV-2, responsible for the Coronavirus Disease ‘COVID-19’ but with a no clear, unified and effective treatment plan, nor definitive therapies for it, but only a variety of potential approaches. The objective of this work was to present, an overview of a variety of therapeutic and preventive approaches that have been applied instead, in a matter to calm the fatal viral pneumonia and developing safe, effective, anti-coronavirus therapeutic agents from naturally derived compounds would make a hopeful solution to end this pandemic. A number of experimental therapies have been rushed into clinical trials for COVID-19 patients, and with medical journals publishing new COVID-19 research studies at breakneck speed, it can be difficult to keep up with the latest news and guidelines. Potential anti-coronavirus therapies can be divided into two categories depending on the target, one acting on the human immune system or human cells, and another, on the virus itself.

CHOICE OF PROSTHODONTIC TREATMENT OF COMPLETE ANODONTIA IN MANDIBULAR ARCH ACCORDING TO THE PATIENT’S PSYCHOLOGICAL TYPE

About 30 – 60% of patients complain on malfunctioning removable laminar dentures whatever the manufacturing method was chosen. An alternative method to correct complete anodontia is the construction of fixed implant-retained prostheses. Plan of prosthetic treatment for individuals with complete anodontia is elaborated based on a number of factors including initial examination, analysis of clinical and additional laboratory findings, and choosing the optimal and accessible option for a patient. The objective of this study was to analyze the impact of the patient’s psychological type on selecting the treatment tactics to correct complete anodontia in the lower jaw and on the level of the patient’s motivation regarding the choice of the prosthetic restoration. Materials and methods. 45 patients with compete anodontia who required prosthodontic treatment were included into the study. The clinical examination was performed in 2 stages. The patient’s psychological type was determined according to the House classification (1950) during the primary clinical examination. The patients were distributed into the groups according to the data obtained. We evaluated the decisions on the proposed priority options of the treatment plan made by the patients of each groups. Results. Our study demonstrated 62.2% of the patients (28 people), who sought help at the prosthetic dentistry clinic, had clearly defined needs. An option of intraosseous dental implants placement and then fixed denture placement without extensive reconstructive interventions was chosen by 8 patients (66.7%) of the study group 1. The patients classified as exacting mind conduct themselves in conformity with the personality characteristics typical for this class in the process of elaborating the treatment plan. 88.9% of people classified as indifferent psychological type tended to choose the simplest and the least expensive treatment options. Conclusions: 1. A key character trait of the patients classified as philosophical minds is the credibility to dentists. Decision making on choosing the optimal option is only possible when patients are completely aware of possible risks and complications. 2. Adherence to a clear treatment plan according to the established requirements is a priority for the patients classified as exacting minds. 3. When making a decision on the treatment plan for the patients with an indifferent psychological type, it is necessary to ensure the patient’s ability to follow all recommendations and prescriptions. 4. When dealing with the patients with hysterical psychological type, the doctor-patient mutual understanding should be built up taking into account the emotional instability of the patients.

Research Progress in the Pathogenesis of Idiopathic Pulmonary Fibrosis with Lung Cancer

特发性肺纤维化（idiopathic pulmonary fibrosis, IPF）是一种原因不明，以弥漫性肺泡炎和肺泡结构紊乱最终导致肺间质纤维化为特征的疾病。针对IPF尚无有效的治疗手段，主要以延缓疾病进展、改善患者生活质量为主。而目前IPF合并肺癌（IPF with lung cancer, IPF-LC）的发病率越来越高，致使患者死亡率明显增加、生活质量显著下降。IPF-LC多见于男性、高龄和吸烟者，是一种临床表现缺乏特异性、无明确治疗方案、中位生存期短、预后较差的致死性疾病。目前IPF-LC发病机制及治疗方案尚不明确。本文就目前IPF-LC的危险因素、发病机制、临床特征和治疗的相关研究进展作简要综述。

Hypoglycaemia and its management in primary care setting.

Hypoglycaemia is common in patients with type 1 diabetes and type 2 diabetes and constitutes a major limiting factor in achieving glycaemic control among people with diabetes. While hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L), symptoms may occur at higher blood glucose levels in individuals with poor glycaemic control. Severe hypoglycaemia is defined as an episode requiring the assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions to assure neurologic recovery. Hypoglycaemia is the most important safety outcome in clinical studies of glucose lowering agents. The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan. A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycaemic goals and promote new therapies to improve quality of life of patients. Data from recent large clinical trials reported low risk of hypoglycaemic events with the use of newer anti-diabetic drugs. Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas. Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of "frailty." Many of such patients may be better treated by the use of GLP-1 receptor agonists or SGLT2 inhibitors rather than insulin. Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia. Patients with impaired awareness of hypoglycaemia benefit from real-time CGM. The diabetes educator is an invaluable resource and can devote the time needed to thoroughly educate the individual to reduce the risk of hypoglycaemia and integrate the information within the entire construct of diabetes self-management. Conversations about hypoglycaemia facilitated by a healthcare professional may reduce the burden and fear of hypoglycaemia among patients with diabetes and their family members. Optimizing insulin doses and carbohydrate intake, in addition to a short warm up before or after the physical activity sessions may help avoiding hypoglycaemia. Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy including administration of rapid-acting insulin analogues rather than human insulin, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction.

Brief admission for patients with emotional instability and self-harm: A qualitative analysis of patients' experiences during crisis.

Previous studies report that individuals diagnosed with borderline personality disorder have been met by negative attitudes from healthcare professionals and their care needs have often been neglected during hospitalizations. When symptoms ofemotional instability are combined with self-harm, the resulting crisis often becomes difficult to handle for patients and healthcare professionals. To meet their care needs during these crises, an intervention called 'brief admission' (BA) has been developed. The purpose of BA is to provide a timeout, in situations of increased stress and threat, in order to foster self-management in a safe environment. In the present study, we explored the following research questions: What are patients' experiences with BA? What do patients consider to be the key components of BA? What improvements are considered relevant by patients? A qualitative design was employed, and 15 patients (13 females, 2 males; mean age 38.5±12.9, range 20-67years) were interviewed using a semi-structured interview guide. Thematic analyses were performed, which yielded four themes related to the patients' experiences: 'a timeout when life is tough', 'it is comforting to know that help exists', 'encouraged to take personal responsibility', and 'it is helpful to see the problems from a different perspective'. Four themes also described the key components: 'a clear treatment plan', 'a smooth admission procedure', 'a friendly and welcoming approach from the staff', and 'daily conversations'. Lastly, three themes described areas for improvements: 'feeling guilty about seeking BA', 'room occupancy issues', and 'differences in staff's competence'. Collectively, the findings indicate that BA constructively supports patients with emotional instability and self-harm during a period of crisis.

Spontaneous Regression of Intraprocedural Carotid Stent Thrombosis Achieved Using Antiplatelet Agents

Acute thrombosis is an uncommon complication during carotid stent intervention.1 In some patients, an intraprocedural carotid stent thrombosis occurs immediately after stent deployment and can lead to a fatal iatrogenic stroke.2 A clear treatment plan to prevent further thrombus progression has not been established to date. We report a patient with successful regression of an intraprocedural carotid stent thrombus without clinical aggravation who received antiplatelet agents during and after intervention.

Can we still manage the relationship with patients?

Can we still manage the relationship with patients?

Experiences of parents and carers in managing asthma in children: a qualitative systematic review.

The objective of the review was to identify, critically appraise and synthesize the best available qualitative evidence to understand the lived experiences of parents and carers caring for a child aged 0-18 years with asthma in any setting and managing their condition. Asthma affects around 14% of children and despite the availability of effective therapies, asthma control is suboptimal and hospitalization rates remain high. Mothers predominantly manage their child's asthma and experience stress and exhaustion due to complex treatments and balancing work and family life. This review provides an understanding of the barriers parents and carers face in managing their child's asthma and highlights the needs of families throughout their asthma journey. The review considered qualitative studies examining the experiences of parents and carers caring for a child with asthma, wheeze or bronchiolitis and managing their condition. Research designs included, but were not limited to, phenomenology, grounded theory, ethnography, and action and feminist research. A comprehensive search using PubMed, CINAHL, Embase, PsycINFO, Web of Science and ProQuest for published and unpublished studies was undertaken in June 2017 and December 2017. Studies published in English from 1972 to 2017 were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used. Seventy-seven qualitative studies were included in this review, including grounded theory, phenomenology and ethnography methodologies. From these 77 studies, 1655 participants from a variety of cultural backgrounds and socio-economic status groups were represented. The methodological quality of included articles was sound and participants' voices were strong. A total of 1161 findings (966 unequivocal and 195 credible) were extracted and grouped into 41 categories, based on similarity in meaning. From the 41 categories, seven synthesized statements were produced: i) Negotiating the meaning of having a child with asthma, ii) Impact on family life, iii) The process of getting a diagnosis and learning about asthma, iv) Relationships with healthcare professionals and the emergency department experience, v) Medication beliefs, concerns and management strategies, vi) With time, parents and carers become more comfortable managing their child's asthma, vii) The need for support. This review highlights the difficulties parents and carers face when caring for a child with asthma and managing their child's condition. Attaining a definitive diagnosis of asthma can be challenging, and parents and carers express uncertainty and fear due to continuing symptoms and repeated hospitalizations. Healthcare professionals should ensure that a clear diagnostic strategy and treatment plan are communicated so parents and carers have an understanding of the pathway to receiving an actual diagnosis. Comprehensive asthma education is essential at the onset of asthma symptoms, with accurate, easy to understand and culturally relevant information. Supportive relationships, with healthcare professionals taking a partnership approach, ensuring adequate time, continuity of care, regular follow-up, and addressing the psychosocial and cultural needs and concerns of parents and carers, are recommended. Support groups and training for education staff is imperative to ensure they can support parents and carers, provide asthma friendly environments and respond appropriately in an asthma emergency.