Clinical Guidelines For Management Research Articles

Performance of thyroid fine needle aspiration biopsy in a low- and middle-income country.

Introduction The 6 categories of the Bethesda System for Reporting Thyroid Cytology (TBSRTC) with associated risk of malignancy (ROM) provide evidence-based clinical management guidelines. This study aimed to determine the ROM and accuracy of FNAB in South Africa (SA). Methods Thyroid specimens from 3 pathology laboratories registered between January 2015 and December 2019 were considered for inclusion. ROM was obtained per TBSRTC category by cytohistological correlation and dividing the total number of specimens with malignant histology by the total number of cases operated. Accuracy was calculated based on the Bethesda category and eventual malignant histology. Results Seventeen thousand seven hundred and seventy-three histology and 4 791 cytology cases were identified. Of the 4 791 cytology cases, 931 (19%) underwent surgery. More than a third (333, 35.8%) of cases were confirmed as malignant following histological assessment, with the majority being benign (584, 62.7%). The ROM for the non-diagnostic and benign categories was 24.3% and 20.5%. The highest ROM was for category VI (91.5%), followed by categories V (69.5%), IV (51.9%) and III (38.8%). Thyroid FNAB had a sensitivity of 73%, specificity of 74%, and overall accuracy of 74%. Conclusion Bethesda categories II and IV have a relatively higher ROM in SA compared to findings from other developed countries. The diagnostic accuracy of thyroid FNAB in SA and the high rate of non-diagnostic diagnoses (38%) require further investigation. A national thyroid registry could provide location-specific data to aid the implementation of appropriate local policies and national guidelines for practicing thyroid surgeons.

Management of chronic kidney disease for Māori in Aotearoa New Zealand: a summary of clinical practice guidelines

aims: The kaupapa of the Caring for Australians and New Zealanders with Kidney Impairment (CARI) Clinical practice guidelines for management of chronic kidney disease for Māori in Aotearoa New Zealand is to provide whānau-centred and evidence-based recommendations to healthcare systems, healthcare providers and healthcare workers. The guidelines include screening, identification, management and system-level responses to chronic kidney disease (CKD) to deliver best practice care to Māori affected by CKD across community, primary and secondary services. methods: The guidelines are funded by the Ministry of Health – Manatū Hauora and are written by a panel of Māori and non-Māori clinicians and literacy experts across Aotearoa New Zealand from Kaupapa Māori organisations, general practice and nephrology units using standardised methods. The guidelines’ methodology included consultation with whānau Māori with lived experience of CKD and primary and secondary care practitioners. Additional guideline development would be required to inform management of CKD for non-Māori in Aotearoa New Zealand. results: The guidelines provide recommendations about equity, governance and accountability, cultural safety, case management, information systems, social determinants of equity and wellbeing and screening. conclusions: Recommendations to health services for Māori with CKD are based on giving effect to Te Tiriti o Waitangi and best practice care to prevent CKD, delaying its progression, treating kidney failure through timely transplantation, delivering in community and providing high-quality symptom management.

Resistant ovary syndrome: Two case reports and a literature review of effective controlled ovarian stimulation in IVF.

Resistant ovary syndrome (ROS) represents a rare reproductive endocrine disorder that is predominantly associated with infertility, characterized by heightened endogenous gonadotropin levels in the presence of a normal ovarian reserve. Patients with ROS typically exhibit a poor response to exogenous gonadotropins during controlled ovarian stimulation (COS). Due to the absence of a universally accepted effective COS protocol, this study aims to contribute to the existing body of literature by detailing 2 successful pregnancies achieved through conventional in vitro fertilization (c-IVF) in patients with ROS, and through retrospective analysis, seeks to elucidate the factors contributing to the successful ovarian stimulation in these cases, with the ultimate goal of establishing clinical guidelines for ROS management. The central challenge addressed in this study pertains to the effective induction of oocyte maturation during c-IVF COS in ROS patients. The study focuses on 2 infertile women diagnosed with ROS who sought to conceive via c-IVF. The patients were subjected to a COS protocol involving pituitary downregulation followed by ovarian stimulation using recombinant follicle-stimulating hormone (r-FSH) and human menopausal gonadotropin (HMG), preceded by 3 cycles of hormone replacement therapy (HRT) pretreatment. The proposed protocol elicited a favorable ovarian response, culminating in the retrieval of numerous mature oocytes and the development of multiple viable embryos via c-IVF, ultimately leading to successful live births post-embryo transfer. Our study suggests that the outlined COS protocol may serve as a viable treatment option for ROS patients aspiring to conceive through c-IVF, thereby potentially expanding the therapeutic repertoire for this challenging condition.

Is there any difference between Eastern and Western clinical practice guidelines in management of gastric cancer?

Gastric cancer (GC) has been known as one of the most common causes of cancer mortality both in Western and Eastern countries. However, there might be differences between how it is managed in different countries. Thus, we aimed to investigate these differences. The most well-known clinical guidelines in field of GC management including Korean GC Association (KGCA), Japanese GC Association (JGCA), National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG), and National Institute for health and Care Excellence (NICE) have been reviewed. The contents of these guidelines were categorized under eight headings including (1) genetic predisposition, (2) prevention, (3) management of gastric polyp, atrophy, dysplasia and metaplasia, (4) diagnosis, (5) pathology and molecular biology, (6) treatment, (7) supportive and palliative care, and (8) follow up. Difference in each section was discussed. Considering KGCA and JGCA as Eastern and NCCN, ESMO, BSG, and NICE as Western guidelines, it is revealed that both sets of guidelines share common practices such as prioritizing comprehensive diagnostic evaluations, personalizing treatment plans, and palliative care. However, main differences can be seen in treatment regimens, the adoption of newer therapies like immunotherapy, and the utilization of emerging techniques such as HIPEC. These differences reflect the diverse clinical landscapes, research focuses, and healthcare systems within these regions.

A Review of Clinical Practice Guidelines for Physiotherapy Management of Patients with Non-Specific Low Back Pain

Background: Despite the availability of various clinical practice guidelines (CPGs) offering evidence-based recommendations, there exists a global diversity in physiotherapy practices for managing patients with non-specific low back pain (NSLBP). In this review, we aim to critically appraise and map the current evidence regarding physiotherapy management for patients with NSLBP. Methods: A search strategy was formulated and searched in MEDLINE, Scopus, EBSCOhost, PEDro and Google Scholar between 2013 and 2023 in English. Critical appraisal was performed using International Centre for Allied Health Evidence (iCAHE) guideline checklist. Results: A total of 12 CPGs met the selection criteria were synthesised. Exercise therapy, physical activity and manual therapy were consistently recommended for patients with NSLBP across most guidelines, irrespective of symptom duration. Cognitive-behavioural therapy was frequently advised for those with chronic NSLBP. However, notable absences of recommendations for electrotherapy, mechanical traction, bed rest, and lumbar corsets in NSLBP management. Moreover, emerging treatments such as shock wave therapy and cognitive-functional therapy were not extensively addressed in the guidelines. Conclusion: Multimodal and active forms of physiotherapy management were predominantly recommended in most of the guidelines. However, there is a clear necessity for updated CPG that effectively integrate biopsychosocial approaches into the management of patients with NSLBP.

Pediatric COVID-19 Response in the Philippines

The COVID-19 pandemic has been an unprecedented global health crisis, affecting individuals of all ages. In thePhilippines, as we continue to combat the virus, we put focus on one particularly vulnerable group: our children.1 As weconfront the complexities of pediatric COVID-19 management, we provide insight into the response strategies establishedto protect the health of our youngest population. At the beginning of the pandemic, the Philippines undertook a comprehensive approach that encompassed travel restrictions,community interventions, robust risk communication, and rigorous testing procedures. These measures were implementedwith the overarching goal of mitigating the impact of COVID-19 and safeguarding the nation’s healthcare system.2 On March 30, 2020, the Philippine General Hospital (PGH) officially became the COVID-19 Referral Center inthe country. It has been more than four years since that fateful day when we had to brace ourselves for what was about tohappen. All of the departments, including the pediatrics department, had risen to the challenge with change in infrastructure,creation of clinical guidelines for COVID-19 management, formulation of infection control measures, and allocation ofprotective equipment and training for health workers.3 The PGH Transfer Command Center (TCC) was in-charge of triaging, decking, and admitting patients to thehospital.3 During the surges, the TCC was besieged with calls from desperate doctors and relatives with COVID-19 ofvarying severity – critical, severe, moderate, mild, and asymptomatic. Several projects and programs have sprung to help withthe pandemic. An algorithm was created at the time by the Class of 1991 UP College of Medicine, which was a quick,simple, complete, easy-to-understand guideline which navigate patients in their homes.4,5 Through a number of medicalprofessional volunteers, the Philippine General Hospital (PGH) COVID Gabay Program was launched to guide families via ateleconsultation platform.6 A community preventive approach included the promotion of mask-wearing, physical distancing, and hand hygiene,aligning with recommendations from global health organizations like the World Health Organization (WHO) andthe Centers for Disease Control and Prevention (CDC).7,8 Locally, the Philippine Pediatric Society has issued a parentsCOVID-19 prevention guide to disease prevention, symptoms, home care, and breastfeeding9, and treatment guidelinesregarding the disease in children were formulated by the Pediatric Infectious Disease Society to be used by the communityand pediatricians10. Initially, COVID-19 vaccines in the Philippines were primarily administered to adults. The vaccination campaigntargeted healthcare workers, senior citizens, and individuals with comorbidities, as well as its level of acceptability in thecommunity.11 The eligibility for pediatric vaccination depended on regulatory approvals and vaccine availability then. Currently,the vaccination program has expanded to include younger age groups along with COVID-19 booster doses. However,vaccine hesitancy especially by the parents has been a challenge brought about by different factors such as exposure to falseinformation amplified by the media, the community, and the health system.12,13 The disruptions caused by the COVID-19 pandemic in the education sector have had profound effects on childrenas Philippines had one of the longest lockdown period worldwide.14 As education was reinstated in October 2020, theeducation department’s approach was a combination of remote learning alternatives, including online platforms, educationaltelevision and radio broadcasts, and printed study materials. However, the significant challenge lies in the disparities insocial circumstances and the absence of adequate resources at home, which has adversely affected numerous students andeducators.14,15 The apprehension and worry about contracting the virus, the cessation of in-person classes, the disturbance of theirusual daily routines, and the reduction in social interactions with schoolmates all contribute to an increased strain on themental health of children.16 In anticipation of the mental health challenges at the pandemic’s outset, the PsychologicalAssociation of the Philippines compiled a roster of complimentary telemedicine consultations. Furthermore, the PhilippineRed Cross initiated a COVID-19 hotline to attend to mental health issues and related concerns. Additionally, theDepartment of Health has launched nationwide campaigns during the National Mental Health Week.17 Our commitment to the well-being of our children during this pandemic is a reflection of our society’s resilience andcompassion. By addressing these challenges and implementing solutions, we can protect the future of our nation. In conclusion, the pediatric COVID-19 response in the Philippines is a critical endeavor that demands our collective effort.We must prioritize the health, education, and emotional well-being of our children as we navigate these challenging times.Let us work together to ensure that no child is left behind in our journey towards a safer and healthier future.  

Utilization of clinical practice guidelines for cancer care in routine practice and during the coronavirus disease 2019 pandemic in India.

The coronavirus disease 2019 (COVID-19) pandemic affected cancer service delivery and the feasibility of following the standard treatment guidelines. The present paper describes the use of clinical care guidelines for cancer management in routine practice and the approach adopted towards cancer care during the COVID-19 pandemic in India. A web-based survey was done in 107 hospitals (including public and private health facilities) that hosted Hospital-Based Cancer Registries under the National Cancer Registry Programme. The participants comprised Principal Investigators of these registries, who were also medical, surgical, and radiation oncology clinicians. The survey was done between May 1, 2021, and July 31, 2021. Participants were provided with a web link for the survey questionnaire, confidential login, and password. The study found high utilization of Clinical Practice Guidelines (CPGs) during practice, with eight out of ten physicians constantly to referring them. The study reported lack of knowledge, skills, and training to administer the treatment based on the guidelines followed by organizational infrastructure and affordability of treatment by the patients as the factors hampering utilization. International clinical guidelines were preferred when compared to national guidelines. The COVID-19 pandemic decreased the use of CPGs, wherein six out of ten clinicians reported their use. Stakeholders who formulate clinical guidelines must consider the practical aspects and feasibility of implementing such guidelines during a pandemic and similar situations. This should be coupled with adequate changes in care practice to ensure optimal care delivery and a continuum of cancer care in routine and pandemic-imposed situations.

Parental experiences in navigating health services for paediatric residual obstructive sleep apnoea: An exploratory qualitative descriptive study.

To explore parents' experiences and perceptions regarding engagement in health services for managing residual paediatric obstructive sleep apnoea (OSA) across levels of care. Qualitative description guided study design. Data were collected through semi-structured interviews with parents of children diagnosed with residual OSA at a university-based sleep clinic. The relevant literature informed the interview guide and was piloted before data collection. Inductive, manifest content analysis was used to describe parents' perceptions and experiences using data-driven categories and sub-categories. Several strategies were employed to ensure rigour in this study. Eight interviews were conducted. Parents' views were organized into five categories: awareness of the sleep issue, interaction with non-sleep specialists, interaction with sleep specialists, interaction with dental professionals, and further actions and support. Parents reported several engagement issues due to their interactions with different care providers. These issues included having to personally identify and raise the sleep problem, feeling that care providers did not take this problem seriously, waiting for an extended period to be referred for sleep services, and receiving conflicting or insufficient treatment recommendations. Overall, parents perceived that their actions and the services received across levels of care were not effective enough to address paediatric OSA. Based on this exploratory qualitative descriptive research, along with developing evidence-based clinical guidelines for paediatric OSA screening and management tailored to different levels of care, strategies intended to improve the engagement of patients and care providers in addressing paediatric OSA should be developed and empirically tested.

Need for standardization and compliance to treatment protocols for COVID-19 within the African Region of the World Health Organization

COVID-19 pandemic changed the face of global health and brought about new issues in global health security and economy. The World Health Organization published guidelines for clinical management of COVID-19 four months after declaration of COVID-19 as a pandemic. Scholarly reviews and studies from member states within WHO AFRO reveals significant deviation from the WHO published protocols on COVID-19. Assessment of national treatment protocols of 30 of 47 WHO AFRO member states showed widespread inappropriate use of antimicrobial agents for patients, which may worsen the global and concerning threat of antimicrobial resistance. There is need for adopting interventions that optimize antimicrobial use in the context of pre- and post-pandemic preparedness to ensure long-term effectiveness and sustainability for antimicrobials. Treatment guidelines are to be adopted or adapted depending on best clinical evidence available. Non-compliance with guidelines might lead to mismanagement of infectious diseases with attendant negative consequences including antimicrobial resistance and misdirection of critical resources and supplies amongst others.

Timing of antibiotic treatment identifies distinct clinical presentations among patients presenting with suspected septic shock.

Recent clinical guidelines for sepsis management emphasize immediate antibiotic initiation for suspected septic shock. Though hypotension is a high-risk marker of sepsis severity, prior studies have not considered the precise timing of hypotension in relation to antibiotic initiation and how clinical characteristics and outcomes may differ. Our objective was to evaluate antibiotic initiation in relation to hypotension to characterize differences in sepsis presentation and outcomes in patients with suspected septic shock. Adults presenting to the emergency department (ED) June 2012-December 2018 diagnosed with sepsis (Sepsis-III electronic health record [EHR] criteria) and hypotension (non-resolving for ≥30 min, systolic blood pressure<90mmHg) within 24h. We categorized patients who received antibiotics before hypotension ("early"), 0-60 min after ("immediate"), and>60 min after ("late") treatment. Among 2219 patients, 55% received early treatment, 13% immediate, and 32% late. The late subgroup often presented to the ED with hypotension (median 0 min) but received antibiotics a median of 191 min post-ED presentation. Clinical characteristics notable for this subgroup included higher prevalence of heart failure and liver disease (p<0.05) and later onset of systemic inflammatory response syndrome (SIRS) criteria compared to early/immediate treatment subgroups (median 87 vs. 35 vs. 20 min, p<0.0001). After adjustment, there was no difference in clinical outcomes among treatment subgroups. There was significant heterogeneity in presentation and timing of antibiotic initiation for suspected septic shock. Patients with later treatment commonly had hypotension on presentation, had more hypotension-associated comorbidities, and developed overt markers of infection (eg, SIRS) later. While these factors likely contribute to delays in clinician recognition of suspected septic shock, it may not impact sepsis outcomes.

Erratum to Clinical Management Guidelines for Intrahepatic Cholestasis of Pregnancy. Volume 6, Issue 1, Janurary 2024

Erratum to Clinical Management Guidelines for Intrahepatic Cholestasis of Pregnancy. Volume 6, Issue 1, Janurary 2024

Impact of the revised VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder for couples and families: Commentary on Lang etal. (2024).

Impact of the revised VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder for couples and families: Commentary on Lang etal. (2024).

Abstract 804: Temporal trends and disparities by race and ethnicity in treatment of women diagnosed with advanced hormone receptor-positive breast cancer: A SEER-Medicare analysis

Abstract Background: The clinical guidelines for management of advanced hormone receptor-positive (HR+) breast cancer (BC) have changed in the past decade with the addition of novel drug classes. We assessed temporal patterns of treatment initiation among women diagnosed with advanced HR+ BC and examined disparities in treatment initiation by race and ethnicity. Methods: Women aged ≥65 years diagnosed with stage IV or metastatic HR+ BC between 2010-2019 were identified in SEER-Medicare. Poisson models were used to estimate age-adjusted annual incidence rates (IR) and 95% confidence intervals (CIs) for treatment initiation within 12 months of BC diagnosis independently by human epidermal growth factor receptor 2 (HER2) status. Age-adjusted incidence rate ratios (IRR) and 95% CIs were estimated to compare rates of initiation among non-Hispanic Black (NHB) and Hispanic patients with non-Hispanic White (NHW) patients. Results: Among 3,476 eligible patients with a mean age of 76.7 (SD: 7.5) years at diagnosis, 79.6% were NHW, 9.5% were NHB, and 6.0% were Hispanic. Among 2,668 women with HR+/HER2- BC, most initiated on aromatase inhibitors (AIs) alone (56.7%), followed by AIs with palbociclib (12.6%). There was a temporal increase in rates of initiation of AIs with palbociclib (IR [95% CI] per 1000 person-years: 252.8 [240.8, 265.4] in 2015 and 343.9 [330.8, 357.7] in 2019. We did not observe significant differences in rates of initiation of AIs alone or with palbociclib by race and ethnicity. Among 537 HR+/HER2+ patients, 25.0% initiated on AIs alone, 24.6% on pertuzumab and trastuzumab with chemotherapy, 14.3% on trastuzumab with chemotherapy, and 9.1% on AIs and trastuzumab with chemotherapy. IRs (95% CI) for initiation of pertuzumab and trastuzumab with chemotherapy increased from 175.6 (146.3, 210.9) in 2013 to 756.5 (698.3, 819.5) in 2019, while rates for trastuzumab with chemotherapy declined from 963.1 (809.4, 1146.0) in 2010 to 88.4 (72.6, 107.5) in 2019. Rates of initiation of AIs and trastuzumab with chemotherapy remained constant over time. Compared to NHW, NHB and Hispanic women were less likely to initiate pertuzumab and trastuzumab with chemotherapy (IRR [95% CI]: 0.52 [0.27, 1.00] and 0.54 [0.24, 1.23] respectively) and more likely to initiate AIs alone (IRR [95% CI]: 2.23 [1.39, 3.55] and 2.98 [1.69, 5.24] respectively). Conclusions: We observed a temporal increase in the initiation of AIs with palbociclib among patients with advanced HR+/HER2- BC. Among patients with HR+/HER2+ BC, rates of initiating pertuzumab and trastuzumab with chemotherapy increased while rates of trastuzumab with chemotherapy declined. The observed differential management of NHB and Hispanic compared with NHW patients with HR+/HER2+ BC using pertuzumab and trastuzumab with chemotherapy and AIs alone requires further investigation. Citation Format: Kexin Zhu, Elisa Bandera, Farzin Khosrow-Khavar. Temporal trends and disparities by race and ethnicity in treatment of women diagnosed with advanced hormone receptor-positive breast cancer: A SEER-Medicare analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 804.

Singapore tuberculosis (TB) clinical management guidelines 2024: A modified Delphi adaptation of international guidelines for drug-susceptible TB infection and pulmonary disease

Introduction: Tuberculosis (TB) remains endemic in Singapore. Singapore’s clinical practice guidelines for the management of tuberculosis were first published in 2016. Since then, there have been major new advances in the clinical management of TB, ranging from diagnostics to new drugs and treatment regimens. The National TB Programme convened a multidisciplinary panel to update guidelines for the clinical management of drug-susceptible TB infection and disease in Singapore, contextualising current evidence for local practice. Method: Following the ADAPTE framework, the panel systematically reviewed, scored and synthesised English-language national and international TB clinical guidelines published from 2016, adapting recommendations for a prioritised list of clinical decisions. For questions related to more recent advances, an additional primary literature review was conducted via a targeted search approach. A 2-round modified Delphi process was implemented to achieve consensus for each recommendation, with a final round of edits after consultation with external stakeholders. Results: Recommendations for 25 clinical questions spanning screening, diagnosis, selection of drug regimen, monitoring and follow-up of TB infection and disease were formulated. The availability of results from recent clinical trials led to the inclusion of shorter treatment regimens for TB infection and disease, as well as consensus positions on the role of newer technologies, such as computer-aided detection-artificial intelligence products for radiological screening of TB disease, next-generation sequencing for drug-susceptibility testing, and video observation of treatment. Conclusion: The panel updated recommendations on the management of drug-susceptible TB infection and disease in Singapore.

Singapore tuberculosis (TB) clinical management guidelines 2024: A modified Delphi adaptation of international guidelines for drug-susceptible TB infection and pulmonary disease

Introduction: Tuberculosis (TB) remains endemic in Singapore. Singapore’s clinical practice guidelines for the management of tuberculosis were first published in 2016. Since then, there have been major new advances in the clinical management of TB, ranging from diagnostics to new drugs and treatment regimens. The National TB Programme convened a multidisciplinary panel to update guidelines for the clinical management of drug-susceptible TB infection and disease in Singapore, contextualising current evidence for local practice. Method: Following the ADAPTE framework, the panel systematically reviewed, scored and synthesised English-language national and international TB clinical guidelines published from 2016, adapting recommendations for a prioritised list of clinical decisions. For questions related to more recent advances, an additional primary literature review was conducted via a targeted search approach. A 2-round modified Delphi process was implemented to achieve consensus for each recommendation, with a final round of edits after consultation with external stakeholders. Results: Recommendations for 25 clinical questions spanning screening, diagnosis, selection of drug regimen, monitoring and follow-up of TB infection and disease were formulated. The availability of results from recent clinical trials led to the inclusion of shorter treatment regimens for TB infection and disease, as well as consensus positions on the role of newer technologies, such as computer-aided detection-artificial intelligence products for radiological screening of TB disease, next-generation sequencing for drug-susceptibility testing, and video observation of treatment. Conclusion: The panel updated recommendations on the management of drug-susceptible TB infection and disease in Singapore.

Nutrition counsellors’ recommended eating patterns for individuals with type 2 diabetes in the USA

IntroductionMultiple eating patterns can promote glycaemic control and weight loss among patients with type 2 diabetes mellitus (T2D). Clinical practice guidelines for T2D management encourage health professionals to guide patients’...

The 2023 AO Spine-Praxis Guidelines in Acute Spinal Cord Injury: What Have We Learned? What Are the Critical Knowledge Gaps and Barriers to Implementation?

Narrative summary of the 2023 AO Spine-Praxis clinical practice guidelines for management in acute spinal cord injury (SCI). The objective of this article is to summarize the key findings of the clinical practice guidelines for the optimal management of traumatic and intraoperative SCI (ISCI). This article will also highlight potential knowledge translation opportunities for each recommendation and discuss important knowledge gaps and areas of future research. Systematic reviews were conducted according to accepted methodological standards to evaluate the current body of evidence and inform the guideline development process. The summarized evidence was reviewed by a multidisciplinary guidelines development group that consisted of international multidisciplinary stakeholders. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the certainty of the evidence for each critical outcome and the "evidence to recommendation" framework was used to formulate the final recommendations. The key recommendations regarding the timing of surgical decompression, hemodynamic management, and the prevention, diagnosis, and management of ISCI are summarized. While a strong recommendation was made for early surgery, further prospective research is required to define what constitutes sufficient surgical decompression, examine the role of ultra-early surgery, and assess the impact of early surgery in different SCI phenotypes, including central cord syndrome. Furthermore, additional investigation is required to evaluate the impact of mean arterial blood pressure targets on neurological recovery and to determine the utility of spinal cord perfusion pressure measurements. Finally, there is a need to examine the role of neuroprotective agents for the treatment of ISCI and to prospectively validate the new AO Spine-Praxis care pathway for the prevention, diagnosis, and management of ISCI. To optimize the translation of these guidelines into practice, important barriers to their implementation, particularly in underserved areas, need to be explored. Ultimately, these recommendations will help to establish more personalized approaches to care for SCI patients. The recommendations from the 2023 AO Spine-Praxis guidelines not only highlight the current best practice in the management of SCI, but reveal critical knowledge gaps and barriers to implementation that will help to guide further research efforts in SCI.

Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review.

Systematic review update. Interventions that aim to optimize spinal cord perfusion are thought to play an important role in minimizing secondary ischemic damage and improving outcomes in patients with acute traumatic spinal cord injuries (SCIs). However, exactly how to optimize spinal cord perfusion and enhance neurologic recovery remains controversial. We performed an update of a recent systematic review (Evaniew et al, J. Neurotrauma 2020) to evaluate the effects of Mean Arterial Pressure (MAP) support or Spinal Cord Perfusion Pressure (SCPP) support on neurological recovery and rates of adverse events among patients with acute traumatic SCI. We searched PubMed/MEDLINE, EMBASE and ClinicalTrials.gov for new published reports. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We implemented the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to rate confidence in the quality of the evidence. From 569 potentially relevant new citations since 2019, we identified 9 new studies for inclusion, which were combined with 19 studies from a prior review to give a total of 28 studies. According to low or very low quality evidence, the effect of MAP support on neurological recovery is uncertain, and increased SCPP may be associated with improved neurological recovery. Both approaches may involve risks for specific adverse events, but the importance of these adverse events to patients remains unclear. Very low quality evidence failed to yield reliable guidance about particular monitoring techniques, perfusion ranges, pharmacological agents, or durations of treatment. This update provides an evidence base to support the development of a new clinical practice guideline for the hemodynamic management of patients with acute traumatic SCI. While avoidance of hypotension and maintenance of spinal cord perfusion are important principles in the management of an acute SCI, the literature does not provide high quality evidence in support of a particular protocol. Further prospective, controlled research studies with objective validated outcome assessments are required to examine interventions to optimize spinal cord perfusion in this setting.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction.

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.