Clinical Management Algorithm Research Articles

Paucity of Published Data and Protocols for Hypoglycemia Management in Long-term Care.

Background: Older people with diabetes are at high risk for hypoglycemia. Implementing a hypoglycemia treatment protocol in long-term care (LTC) settings may positively affect patient-related outcomes and health care resource utilization and costs. Anecdotal experience indicates little has been studied and published regarding this clinical practice. Objective: To identify hypoglycemia treatment protocols established for LTC settings and assess their effects on patient-related outcomes and health care resource use. Data Sources: The authors performed a systematic literature search of English-language articles and abstracts published between January 1, 2003 (PubMed), or 2018 (Google Scholar) and May 10, 2023. Search terms were "hypoglycemia," "diabetes mellitus," "longterm care," "nursing facilities," "assisted living facilities," "geriatrics," "elderly," "aged," "disabled," "disease management," "evidence-based medicine," "clinical protocols," "guideline," "glucagon," and/or "blood glucose." Included were publications with hypoglycemia treatment and management protocols or hypoglycemia-specific recommendations for LTC settings. DATA SYNTHESIS: The authors identified 405 articles and abstracts, removed 36 duplicates, screened 369 titles/ abstracts, and analyzed the full text for 93. Five met the inclusion criteria. Two originated from the American Diabetes Association: 2016 position statement regarding the management of diabetes in LTC and skilled nursing facilities, and 2023 standard-of-care guideline for managing older people with diabetes. One included the results after implementing an overall diabetes clinical care management algorithm in LTC facilities. A 2020 abstract and 2019 article were the only 2 publications involving specific hypoglycemia treatment protocols in LTC settings. Conclusion: This systematic literature search identified lack of published hypoglycemia treatment protocols in LTC settings and their effects on patient outcomes.

The foregut in cystic fibrosis.

The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomachto the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.

Surgical treatment of multiple magnet ingestion by children: A single-center experience from China.

The incidence of magnet ingestion in children has escalated concurrent with the rise in popularity of magnetic playthings, bearing the capacity to induce substantial morbidity. The objective of this study was to encapsulate our accumulated expertise in handling pediatric cases featuring multiple magnetic foreign bodies within the gastrointestinal tract sometimes necessitating surgical intervention, as well as to formulate a clinical management algorithm. This was a retrospective review of patients with multiple magnetic foreign bodies in the digestive tract, admitted to Shenzhen Children's Hospital, between January 2018 and December 2022. A total of 100 cases were included in this study, including 66 males and 34 females. The main clinical manifestation ns were abdominal pain and vomiting. All patients had abdominal x-ray, all of which indicated foreign bodies in the digestive tract. 33 patients had to undergo a surgical intervention. Among these cases, the gastrointestinal complications occurred in 31 patients, including gastric rupture (n = 9), intestinal obstruction (n = 11) and intestinal perforation (n = 30). Postoperative intestinal obstruction occurred in 6 children. There was no statistical significant difference in age and gender between the Surgical group and Non-surgical group, but the Surgical group had a higher number of magnets ([7.5(2-44) vs 4(2-20)], p = 0.009), a longer interval between time of misingestion to clinical visit ([48(7.2-480) vs 5(2-336)]hours, p < 0.001), and a longer length of hospital stay ([10(6-19) vs 2(1-8)]days, p < 0.001). Multiple magnet ingestion in children can lead to serious complications and carry severe risks. Timely diagnosis and effective treatment are crucial for managing such patients.

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis.

Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation. If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.

Exploring the factors affecting classification and reporting of uncertain prenatal microarray findings, using a "virtual fetus" model-a pilot study.

Significant discrepancy exists between laboratories in classification and reporting of copy number variants (CNVs). Studies exploring factors affecting prenatal CNV management are rare. Our "virtual fetus" pilot study examines these factors. Ten prenatally diagnosed CNVs of uncertain significance (VUS)>1Mb, encompassing OMIM-morbid genes, inherited from healthy parents, were classified by 15 MD geneticists from laboratory, prenatal, and preimplantation genetic testing (PGT) units. Geneticists addressed factors affecting classification, obligation to report, and recommendation for invasive testing or PGT. CNVs were classified likely benign (10.7%), VUS (74.7%), likely pathogenic (8.7%), or pathogenic (6.0%). Classification discrepancy was higher for losses versus gains. Classifying pathogenic/likely pathogenic was more common for losses (adjusted odds ratio [aOR] 10.9, 95% CI 1.55-76.9), and geneticists specializing in gynecology (aOR 4.9, 95% CI 1.03-23.3). 84.0% of respondents would report CNVs, depending on classification and family phenotype. Invasive testing in pregnancies was recommended for 29.3% of CNVs, depending on theclassification and geneticist's specialization. PGT was recommended for 32.4%, depending on classification, experience years, and family's phenotype (38.0% for patients undergoing in vitro fertilization irrespectively, 26.7% otherwise). Factors affecting CNV classification/reporting are mainly dosage, family phenotype, geneticist specialization and experience. Understanding factors from our pilot study may facilitate developing an algorithm for clinical consensus and optimal management.

Repeat placental growth factor-based testing in women with suspected preterm pre-eclampsia (PARROT-2): a multicentre, parallel-group, superiority, randomised controlled trial

Placental growth factor (PlGF)-based testing has high diagnostic accuracy for predicting pre-eclampsia needing delivery, significantly reducing time to diagnosis and severe maternal adverse outcomes. The clinical benefit of repeat PlGF-based testing is unclear. We aimed to determine whether repeat PlGF-based testing (using a clinical management algorithm and nationally recommended thresholds) reduces adverse perinatal outcomes in pregnant individuals with suspected preterm pre-eclampsia. In this multicentre, parallel-group, superiority, randomised controlled trial, done in 22 maternity units across England, Scotland, and Wales, we recruited women aged 18 years or older with suspected pre-eclampsia between 22 weeks and 0 days of gestation and 35 weeks and 6 days of gestation. Women were randomly assigned (1:1) to revealed repeat PlGF-based testing or concealed repeat testing with usual care. The intervention was not masked to women or partners, or clinicians or data collectors, due to the nature of the trial. The trial statistician was masked to intervention allocation. The primary outcome was a perinatal composite of stillbirth, early neonatal death, or neonatal unit admission. The primary analysis was by the intention-to-treat principle, with a per-protocol analysis restricted to women managed according to their allocation group. The trial was prospectively registered with the ISRCTN registry, ISRCTN 85912420. Between Dec 17, 2019, and Sept 30, 2022, 1253 pregnant women were recruited and randomly assigned treatment; one patient was excluded due to randomisation error. 625 women were allocated to revealed repeat PlGF-based testing and 627 women were allocated to usual care with concealed repeat PlGF-based testing (mean age 32·3 [SD 5·7] years; 879 [70%] white). One woman in the concealed repeat PlGF-based testing group was lost to follow-up. There was no significant difference in the primary perinatal composite outcome between the revealed repeat PlGF-based testing group (195 [31·2%]) of 625 women) compared with the concealed repeat PlGF-based testing group (174 [27·8%] of 626 women; relative risk 1·21 [95% CI 0·95-1·33]; p=0·18). The results from the per-protocol analysis were similar. There were four serious adverse events in the revealed repeat PlGF-based testing group and six in the concealed repeat PlGF-based testing group; all serious adverse events were deemed unrelated to the intervention by the site principal investigators and chief investigator. Repeat PlGF-based testing in pregnant women with suspected pre-eclampsia was not associated with improved perinatal outcomes. In a high-income setting with a low prevalence of adverse outcomes, universal, routine repeat PlGF-based testing of all individuals with suspected pre-eclampsia is not recommended. Tommy's Charity, Jon Moulton Charitable Trust, and National Institute for Health and Care Research Guy's and St Thomas' Biomedical Research Centre.

An objective comparative study of non-surgical cleansing techniques and cleanser types in bacterial burden management.

Cleansing is a vital component of effective wound hygiene and biofilm management, often accomplished through vigorous mechanical action or through soaking with moistened gauze. In the present study, a quantitative comparison of the effectiveness of different cleansing techniques and solutions in removing bacteria was conducted on 71 chronic wounds using bacterial fluorescence imaging as a real-time diagnostic for moderate to high bacterial loads. Vigorous gauze cleansing for 30 s proved most effective by reducing bacterial fluorescence by 33.99%, surpassing 10-min soaking in bacterial reduction (13.24%). Among different cleansers, no statistically significant differences in effectiveness were observed, but povidone-iodine showed the strongest trend towards bacterial reduction. Sub-analysis highlighted the superiority of antiseptic cleansers over saline and gentle soap (-33.30% vs. -1.80% bacterial reduction respectively). Five percent acetic acid was also shown to be more effective in removing specific bacterial strains (Pseudomonas aeruginosa). Findings from studies like this contribute to refining wound hygiene guidelines and clinical algorithms for bacterial and biofilm management.

Oxygen saturation thresholds in managing sickle cell disease at US children's hospitals.

Adequate oxygen saturation (SpO2 ) is crucial for managing sickle cell disease (SCD). Children with SCD are at increased risk for occult hypoxemia; therefore, understanding SpO2 threshold practices would help identify barriers to oxygen optimization in a population sensitive to oxyhemoglobin imbalances. We investigated SpO2 cutoff levels used in clinical algorithms for management of acute SCD events at children's hospitals across the United States, and determined their consistency with recommended national guidelines (SpO2 >95%). Clinical pathways and algorithms used for the management of vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) in SCD were obtained and reviewed from large children's hospitals in the United States. Responses were obtained from 94% (140/149) of eligible children's hospitals. Of these, 63 (45%) had available clinical algorithms to manage VOC and ACS. SpO2 cutoff was provided in 71.4% (45/63) of clinical algorithms. Substantial variation in SpO2 cutoff levels was noted, ranging from ≥90% to more than 95%. Only seven hospitals (5% of total hospitals and 15.6% of hospitals with clinical algorithms available) specified oxygen cutoffs that were consistent with national guidelines. Hospitals geographically located in the South (46.8%; n=29/62) and Midwest (54.8%; n=17/31) were more likely to have VOC and ACS clinical algorithms, compared to the Northeast (26.5%; n=9/34) and West (36.4%; n=8/22). There is inconsistency in the use of clinical algorithms and oxygen thresholds for VOC and ACS across US children's hospitals. Children with SCD could be at risk for insufficient oxygen therapy during adverse acute events.

Cytomegalovirus Infection: An Underrated Target in Inflammatory Bowel Disease Treatment.

CMV infection is still a matter of concern in IBD patients, especially regarding the disease's relapse management. Why IBD patients, particularly those affected by ulcerative colitis, are more susceptible to CMV reactivation is not totally explained, although a weakened immune system could be the reason. Various techniques, ranging from serology to histology, can be employed to detect intestinal CMV infection; however, there is currently disagreement in the literature regarding the most effective diagnostic test. Furthermore, CMV involvement in steroid resistance has been broadly discussed, but whether CMV infection is a cause or consequence of the disease severity and, consequently, steroid refractoriness is still debated. Its potential contribution to the lack of response to advanced therapy and small molecules must be more valued and wholly explored. In this review, we look at the actual literature on CMV in IBD patients, and we suggest a pragmatic algorithm for clinical practice management of CMV infection.

PP127 Early Health Technology Assessment (HTA) Of Medical Technologies To Inform Subsidy Decision-making In Singapore

IntroductionMedical technologies are evolving rapidly, with many new and expensive technologies entering the market constantly, challenging the sustainability of the public healthcare system. Early health technology assessment (HTA) to inform subsidy decision for innovative medical technologies, before they diffuse into the public healthcare system, may drive appropriate early adoption or curtail inappropriate use. This abstract describes the Agency for Care Effectiveness (ACE)’s experience in conducting early HTAs and key challenges faced.MethodsDuring ACE’s 2021 topic prioritization exercise, ACE took a proactive approach by considering medical technologies identified from horizon scanning (HS) for subsidy evaluation. Two topics were shortlisted from HS. Standard HTA evaluation framework and local clinician consultation were used to define the evaluation scope and clinical pathways. Literature search and appraisal were conducted for safety, effectiveness, and economic evidence. Budget impact estimations and organizational feasibility assessment were additional domains considered for subsidy decision-making by the Ministry of Health Medical Technology Advisory Committee (MTAC).ResultsMTAC did not recommend subsidy for the two technologies due to weak evidence base, largely due to a lack of comparative evidence, small samples, short-term follow-ups, or heterogeneity of population. Additional considerations included potentially high budget impact or organizational feasibility issues such as substantial capital and maintenance cost and infrastructure reconfiguration required. During the evaluation, key challenges of assessing such technologies in their early diffusion within the healthcare system were: (i) differing clinical opinions on whether the technology meets an unmet need; (ii) uncertain place in the clinical management algorithm for the relevant indications; (iii) sparse and weak evidence; (iv) uncertain financial implications to the healthcare system due to a lack of available local costs.ConclusionsEarly HTA on medical technologies identified from HS can be a useful tool to guide subsidy decisions; however, several challenges exist. Careful selection of technologies and timing of evaluation are critical. Seeking stakeholder inputs earlier would ensure shortlisting appropriate technologies with greater clinical need for HTA.

Diagnosis, treatment, and prevention of community-acquired pneumonia in children: an evidence-based clinical practice guideline adapted for the use in Egypt using ‘Adapted ADAPTE’

BackgroundWe recently adapted a guideline for Community-Acquired Pneumonia (CAP) in children to the Egyptian health system. Adaptation of evidence-based clinical practice guidelines to the local healthcare context is a valid alternative to de novo development that can upgrade their application without enforcing a major burden on resources. The objective of this manuscript is to elucidate diagnosis, treatment, and prevention of CAP as well as methods used for the adaptation process to produce the 1st National Guideline for Community-Acquired Pneumonia in children in Egypt using Adapted ADAPTE method. The full process was described extensively with all three phases of set up, adaptation, and finalization. An adaptation group and an external review including clinical content experts and methodologists conducted the process.ResultsThe authors adapted 10 principal categories of recommendations from three source Clinical Practice Guidelines. Recommendations incorporate; common clinical manifestations, indications for hospitalization and intensive care unit admission, indications for laboratory investigations and radiology in diagnosis, choice of empiric antibiotic therapy in the outpatient and hospitalized children with non-complicated CAP and the duration of therapy, the role of influenza antiviral therapy, follow-up anticipated response to therapy, management of non-responding pneumonia, criteria of safe discharge, and prevention of CAP. Many tools were gathered and established to improve implement ability containing two clinical algorithms for management of non-complicated CAP and for non-responding pneumonia in children, pathway for assessment of severity of CAP in primary care facilities, medication tables, simplified Arabic patient information, PowerPoint slide presentation lecture for management of CAP, and online resources.ConclusionThe final clinical guideline supports pediatricians and related healthcare workers with evidence-based applicable guidance for managing community-acquired pneumonia in Egypt. This work demonstrated the efficiency of Adapted ADAPTE and highlighted the importance of a cooperative clinical and methodological professional group for adaptation of national guidelines.

Predictors for Dental Intervention in Children After Dental Injury: A Retrospective Analysis and Literature Review.

This study aimed to explore risk factors for dental intervention in patients presenting to the pediatric emergency department (PED) after dental injury. We retrospectively explored patients aged 0 to 18 years who presented to our PED between 2017 and 2021 after dental injury. Of the total of 830 patients (mean age 7.1 ± 3.9 years, 589 [71.0%] male patients), 237 (28.5%) required dental intervention. All patients with alveolar fractures and those with involvement of permanent teeth with extrusive luxation mandated urgent dental consultation. Additional independent predictors for dental intervention for primary tooth injury were: root fracture (adjusted odds ratio [aOR] 38.4; 95% confidence interval [CI], 3.95-373.22; P = 0.002), facial bone involvement (aOR 12.40; 95% CI, 2.33-65.93; P = 0.003), lateral luxation (aOR 6.9; 95% CI, 4.27-11.27; P < 0.001), extrusive luxation (aOR 6.44; 95% CI, 2.74-15.14; P < 0.001), and avulsion (aOR 2.06; 95% CI, 1.23-3.45; P = 0.006). Additional independent predictors for permanent tooth injury were lateral luxation (aOR 27.8; 95% CI, 6.1-126.6; P < 0.001) and avulsion (aOR 6.8; 95% CI, 2.9-15.9; P < 0.001). Alveolar fracture is a severe dental injury, requiring intervention, for primary and permanent teeth injuries. Tooth luxation with significant mobility or malocclusion, incomplete avulsion, a suspected root involvement, or facial bone injury in the primary teeth and tooth luxation (extrusive/lateral) and avulsion in the permanent teeth dictate urgent dental consultation and intervention. Clinical algorithms for dental injury management are suggested.

Second edition of the Milan System for Reporting Salivary Gland Cytopathology: Refining the role of salivary gland FNA.

The use of standardized reporting systems for non-gynecologic cytopathology has made enormous gains in popularity during the past decade, including for thyroid fine-needle aspiration, urine cytology, serous effusions, pancreas, lymph nodes, lung, and more. In February 2018, the first edition Atlas of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was published. The MSRSGC defines six diagnostic fine-needle aspiration categories encompassing the spectrum of non-neoplastic, benign, and malignant lesions of the salivary glands. The goal of the MSRSGC is to combine each diagnostic category with a defined risk of malignancy and a specific clinical and/or surgical management algorithm. Since its initial publication in 2018, more than 200 studies and commentaries have been published confirming the role of the MSRSGC. The second edition of the MSRSGC, published in July 2023, includes refined risks of malignancy based on systematic reviews and meta-analyses, a new chapter summarizing the use of salivary gland imaging, new advances in ancillary testing, and updates in nomenclature.

Second edition of the Milan System for Reporting Salivary Gland Cytopathology: Refining the role of salivary gland FNA.

The use of standardised reporting systems for non-gynaecologic cytopathology has made enormous gains in popularity during the past decade, including for thyroid fine-needle aspiration, urine cytology, serous effusions, pancreas, lymph nodes, lung and more. In February 2018, the first edition of the Atlas of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was published. The MSRSGC defines six diagnostic fine-needle aspiration categories encompassing the spectrum of non-neoplastic, benign and malignant lesions of the salivary glands. The goal of the MSRSGC is to combine each diagnostic category with a defined risk of malignancy and a specific clinical and/or surgical management algorithm. Since its initial publication in 2018, more than 200 studies and commentaries have been published, confirming the role of the MSRSGC. The second edition of the MSRSGC, published in July 2023, includes refined risks of malignancy based on systematic reviews and meta-analyses, a new chapter summarising the use of salivary gland imaging, new advances in ancillary testing and updates in nomenclature.

Abstract 18534: Catheter-Directed Mechanical Thrombectomy: A PERTinent Paradigm Shift

Introduction: The emergence of catheter-directed mechanical thrombectomy (MT) heralded a paradigm shift in the management of pulmonary embolism (PE). There is a paucity of data on the degree to which the availability of this modality has impacted clinical-decision making by the multidisciplinary Pulmonary Embolism Response Team (PERT). We examine data from a single center experience at a large tertiary hospital to shed light. Research Question: How does the recent emergence of MT as a therapeutic strategy impact the approach of a PERT team? Aim: To examine the degree to which the integration of MT into the clinical decision-making algorithm for PE management has impacted the treatment course recommended by a PERT team. Methods: A retrospective analysis was performed to compare PERT recommendations in a contemporary cohort (10/2020-3/2023) to a historical cohort (1/2015-6/2016) prior to the availability of newer generation mechanical thrombectomy catheters in the same institution. Results: The contemporary cohort consisted of 306 patients, of which 50% were treated with advanced therapies including MT, catheter-directed lysis, systemic tPA, or ECMO. In the historical cohort, 28% of patients received advanced therapies. Of those treated with advanced therapies, 84% were MT and 1% were catheter-directed lysis in the contemporary cohort compared to 6% MT and 31% catheter-directed lysis in the historical PERT cohort. Conclusion: The integration of MT into the PERT decision-making process portends a new era in the management of PE. At our center, it significantly expanded the ambit of advanced therapies, such that a majority of patients now receive some form of advanced therapy, rather than anticoagulation alone. This is in stark contrast with the pre-MT era. These findings underscore the importance of a PERT team’s ability to adapt to evolving treatment modalities and highlights the need for continued multidisciplinary expertise in optimizing care for PE patients.

Advanced machine learning techniques for cardiovascular disease early detection and diagnosis

The identification and prognosis of the potential for developing Cardiovascular Diseases (CVD) in healthy individuals is a vital aspect of disease management. Accessing the comprehensive health data on CVD currently available within hospital databases holds significant potential for the early detection and diagnosis of CVD, thereby positively impacting disease outcomes. Therefore, the incorporation of machine learning methods holds significant promise in the advancement of clinical practice for the management of Cardiovascular Diseases (CVDs). By providing a means to develop evidence-based clinical guidelines and management algorithms, these techniques can eliminate the need for costly and extensive clinical and laboratory investigations, reducing the associated financial burden on patients and the healthcare system. In order to optimize early prediction and intervention for CVDs, this study proposes the development of novel, robust, effective, and efficient machine learning algorithms, specifically designed for the automatic selection of key features and the detection of early-stage heart disease. The proposed Catboost model yields an F1-score of about 92.3% and an average accuracy of 90.94%. Therefore, Compared to many other existing state-of-art approaches, it successfully achieved and maximized classification performance with higher percentages of accuracy and precision.

Digitalizing Clinical Guidelines: Experiences in the Development of Clinical Decision Support Algorithms for Management of Childhood Illness in Resource-Constrained Settings.

Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings.

Algorithm for the clinical management of osteoarthritis in the family health strategy

Objectives: To develop an effective algorithm for the clinical management of osteoarthritis in the family health strategy, aiming to improve early diagnosis, appropriate treatment, and the quality of life of patients. Methods: Qualitative study where primary care physicians were invited to respond to a questionnaire regarding personal aspects of the professionals, as well as technical knowledge on the diagnosis and follow-up of osteoarthritis. Results: The profile of the general practitioner in Teresina's Family Health Strategy (ESF) is a younger professional (&lt;50 years old), with more than 5 years of experience in primary care, who regularly undergoes scientific updates, and feels capable of diagnosing osteoarthritis using simple imaging exams. They identify the lack of health promotion programs and multidisciplinary teams as challenges in the diagnosis and follow-up of these patients. They consider projects aimed at health promotion for these patients and the development of osteoarthritis management protocols specifically for primary care to be of utmost importance. Conclusion: Due to the high incidence of referrals to specialists, it is of paramount importance to implement clinical management algorithms for osteoarthritis in primary care.

Menière's Syndrome Associated With Fibrous Dysplasia of the Temporal Bone.

Menière's Syndrome Associated With Fibrous Dysplasia of the Temporal Bone.

Reducing oral steroid intolerability and drug costs for acute wheezers: A retrospective evaluation of a clinical management algorithm in a Pediatric Emergency Department.

To retrospectively evaluate a clinical management algorithm for acute wheezers in a UK Pediatric Emergency Department (PED). Acute wheezing attacks are a leading cause of PED attendances and inpatient admissions. Prednisolone, a routine treatment, is intolerable in almost one-third of children, requiring repeated dosing, which may prolong length of stay (LOS). To address this problem, we: (1) developed an acute management algorithm (concise, single-sided flow-chart, instructing immediate management); (2) modified the OCS regime from prednisolone (1 mg/kg, 3-day course) to dexamethasone (600 then 300 mcg/kg); (3) and disseminated guidance regionally. Written information-handouts, e-mails, and posters-were followed-up with verbal reinforcement. We implemented the algorithm in 2017 and revised it further in 2018. In 2019, we retrospectively collected data on 100 acute wheeze attendances (those requiring OCS, aged 2-14), between October and December in 2016, 2017, and 2018 (n = 300), and assessed outcomes. Over a 48-month period, we reduced OCS intolerability by 67.2% and OCS drug costs by 85.8% (saving £41,470.14), while not significantly influencing the other outcomes. Reduced intolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze algorithm and modifying the OCS to single-dose dexamethasone (300 mcg/kg).