Clinical Practice Guidelines For Patients Research Articles

Interstitial Lung Disease Associated with Systemic Sclerosis.

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by a tripod combining vasculopathy, fibrosis, and immune-mediated inflammatory processes. The prevalence of interstitial lung disease (ILD) in SSc varies according to the methods used to detect it, ranging from 25 to 95%. The fibrotic and vascular pulmonary manifestations of SSc, particularly ILD, are the main causes of morbidity and mortality, contributing to 35% of deaths. Although early trials were conducted with cyclophosphamide, more recent randomized controlled trials have been performed to assess the efficacy and tolerability of several medications, mostly mycophenolate, rituximab, tocilizumab, and nintedanib. Although many uncertainties remain, expert consensus is emerging to optimize the therapeutic management and to provide clinicians with evidence-based clinical practice guidelines for patients with SSc-ILD. This article provides an overview, in the light of the latest advances, of the available evidence for the diagnosis and management of SSc-ILD.

An analysis of the recommendations of the 2022 Society for Vascular Surgery clinical practice guidelines for patients with asymptomatic carotid stenosis

ObjectivePatients with asymptomatic carotid artery stenosis currently account for the majority of carotid interventions performed in the United States; therefore, the following article will review the 2022 Society for Vascular Surgery (SVS) clinical practice guidelines perspective in treating patient with asymptomatic carotid stenosis. MethodsA systemic review and meta-analysis were conducted by the evidence practice center of the Mayo Clinic using a specified population, intervention, comparison, outcome (PICO) framework. ResultsBased on published randomized trials and related supporting evidence, the following were noted: the SVS recommends that patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke, provided the patient has a life expectancy of 3 to 5 years with risk of perioperative stroke and death not exceeding 3%. The type of carotid intervention should be based on the presence or absence of high-risk criteria for each specified intervention. Data from CREST, ACT, and the Vascular Quality Initiative suggest that certain properly selected asymptomatic patients can be treated with carotid stenting with equivalent outcome to CEA in the hands of experienced interventionalists. The institutions and operator performing carotid stenting must exhibit expertise sufficient to meet the established American Heart Association guidelines for treatment of patient with asymptomatic carotid stenosis (ie, combined stroke/death rate of less than 3%). ConclusionsSVS recommends that low surgical risk patients with asymptomatic carotid stenosis of ≥70% to be treated with CEA with best medical therapy over medical therapy alone for the long-term prevention of stroke/death (GRADE 1B). Carotid intervention should also be based on the presence or absence of high-risk criteria for each specified intervention (ie, CEA, TCAR, and TFCAS).

Factors influencing adherence to clinical practice guidelines in patients with suspected chronic coronary syndrome: a qualitative interview study in the ambulatory care sector in Germany

BackgroundChronic coronary syndrome (CCS) is a potentially progressive clinical presentation of coronary artery disease (CAD). Clinical practice guidelines (CPGs) are available for prevention, diagnosis, and treatment. Embedded in the “ENLIGHT-KHK” healthcare project, a qualitative study was conducted to identify factors that influence guideline adherence from the perspective of general practitioners (GPs) and cardiologists (CA) in the ambulatory care sector in Germany.MethodsGPs and CAs were surveyed via telephone using an interview guide. The respondents were first asked about their individual approach to caring for patients with suspected CCS. Subsequently, the accordance of their approach with guideline recommendations was addressed. Finally, potential measures for assisting with guideline adherence were discussed. The semi-structured interviews were transcribed verbatim and analysed using a qualitative content analysis in accordance with Kuckartz and Rädiker. Factors influencing adherence to CPGs were categorised by assessing whether they (i) inhibited or facilitated guideline adherence, (ii) played a role in patients at risk of CCS or with suspected or known CCS, (iii) were mentioned in implicit or explicit thematic reference to CPGs, and (iv) were declared a practical problem.ResultsBased on interviews with ten GPs and five CAs, 35 potential influencing factors were identified. These emerged at four levels: patients, healthcare providers, CPGs, and the healthcare system. The most commonly cited barrier to guideline adherence among the respondents was structural aspects at the system level, including reachability of providers and services, waiting times, reimbursement through statutory health insurance (SHI) providers, and contract offers. There was a strong emphasis on interdependencies between factors acting at different levels. For instance, poor reachability of providers and services at the system level may result in inexpedience of guideline recommendations at the CPG level. Likewise, poor reachability of providers and services at the system level may be aggravated or alleviated by factors such as diagnostic preferences at the patient level or collaborations at the provider level.ConclusionsTo assist with adherence to CPGs regarding CCS, promoting measures may be needed that account for interdependencies between barriers and facilitators at various healthcare levels. Respective measures should consider medically justified deviations from guideline recommendations in individual cases.Trial registrationGerman Clinical Trials Register: DRKS00015638; Universal Trial Number (UTN): U1111-1227-8055.

Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure.

Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.

Demands on Health Information and Clinical Practice Guidelines for Patients from the Perspective of Adults with Mental Illness and Family Members: A Qualitative Study with In-Depth Interviews.

(1) Background: "Patient health information" promote health literacy. "Patient guidelines" as a sub group reflect the current evidence about illnesses and treatment options adapted to the needs of laypersons. Little is known about factors promoting and hindering their use by people affected by mental illness and their relatives. (2) Methods: Telephone interviews (N = 15; n = 4 adults affected by mental illness, n = 5 relatives, n = 6 both applicable) were conducted according to the Sørensen model of health literacy. Data were recorded, transcribed and content-analyzed following Mayring. (3) Results: Health information is used regularly by individuals affected by mental illness and their relatives, but "patient guidelines" are largely unknown. Yet, there is a great willingness to use them. Main barriers are a lack of statistical knowledge, the complexity of health-related topics and cognitive impairment sometimes accompanying mental illnesses. Target group-oriented adaptation as well as transparent and even-handed presentation of (dis-)advantages of treatment options can increase trust. (4) Conclusions: Health information and guidelines can help affected persons and relatives to make treatment decisions by conveying unbiased, up-to-date knowledge. Target group-specific adaptations should be made for psychiatric illnesses and features specific to mental illnesses compared to physical illnesses should be included. Clinical practice guidelines must be distributed more widely to increase their impact.

Effectiveness and safety of Korean medicine treatment based on the clinical practice guidelines in patients with acute peripheral facial palsy: A protocol for a multicenter, prospective, observational study.

Introduction:Peripheral facial palsy (PFP) results in weakness or paralysis of the affected side of the face. In Korea, there is a high demand for Korean medicine treatment for PFP. The clinical practice guidelines (CPGs) of Korean medicine for facial palsy were developed; however, there remains insufficient evidence to support the effectiveness and safety of Korean medicine treatment. Thus, this study aimed to evaluate the effectiveness and safety of Korean medicine treatment based on the CPGs in patients with acute PFP.Methods:This is a multicenter, prospective, observational study. The participants will be recruited from one Korean medicine hospital and eight Korean medicine clinics. The participants will receive Korean medicine treatments based on the CPGs, fill in survey questionnaires, and undergo electrophysiologic testing. The changes in House-Brackmann (H-B) grade, movement of the lip and eye, symptoms related to or accompanied by facial palsy, Facial Disability Index, EuroQol 5-dimension 5-level (EQ-5D-5L), and EuroQol Visual Analogue Scale (EQ-VAS), and the results of electromyography (EMG), electroneurography (ENoG), and Blink Reflex test will be analyzed. For the safety analysis, adverse events will be recorded, and for the feasibility analysis, the results of the Was It Worth It questionnaire will be assessed.Conclusion:We expect to draw real-world clinical data on the effectiveness and safety of Korean medicine treatment based on the CPGs in patients with acute PFP from this study. It would be the basis for complementing and improving the CPGs and provide the basis of clinical and policy decision-making.Trial registration:This study was approved by the Institutional Review Board of Kyung Hee University Korean Medicine Hospital (2021-06-005-001), and registered with the Korean Clinical Trial Registry (CRIS), Republic of Korea (KCT0006562).

Retrospective Comparative Analysis of Clinical and Imaging Features of Craniocervical Artery Dissection: Spontaneous CAD vs. Minor Traumatic CAD.

Background and ObjectivesCraniocervical artery dissection (CAD) is the most common cause of ischemic stroke in young adults. The etiologies of CAD can be classified into three types, such as spontaneous (sCAD), minor traumatic (mtCAD), and genetic origin. Recent studies indicated that clinical presentations and imaging features could guide management and inform prognosis. This retrospective analysis sought to compare the clinical and imaging features of sCAD vs. mtCAD in providing evidence-based advice on medical treatment, functional rehabilitation, secondary stroke prevention, and prognosis, ultimately formulating clinical guidelines in managing CAD.MethodsIn total, 148 patients with CAD were identified from the medical records database and subdivided into sCAD and mtCAD based on the clinical presentations and imaging features. A retrospective comparative analysis was performed according to their clinical presentations and imaging features.ResultsPatients with mtCAD are significantly younger than sCAD with 120 cases of sCAD average aged 43.61 ± 12.75, while 28 cases of mtCAD average aged 35.68 ± 14.54. Patients with mtCAD had more cases of neck pain compared to sCAD. Patients with mtCAD had more cases of CAD at extracranial locations compared to sCAD. Patients with mtCAD had more cases of multiple site dissection compared to sCAD. Double lumen and intramural haematoma are the most common imaging findings with mtCAD patients having statistical significantly more cases of intramural haematoma and long tapering stenosis.ConclusionPatients with mtCAD were presented at a much younger age with symptoms of neck pain compared to sCAD. Patients with mtCAD predominantly presented at extracranial sites with more prominent features of multiple site dissection, intramural haematoma, and long tapering stenosis. These clinical and imaging features can translate into clinical practice guidelines for patients with CAD to improve the optimal functional outcome and reduce both morbidity and mortality.

Factors Associated with Adherence to Clinical Practice Guidelines for Patients with Type 2 Diabetes Mellitus: Results of a Spanish Delphi Consensus.

Objective To assess factors associated with adherence to clinical practice guidelines (CPGs) for type 2 diabetes mellitus (T2DM). Methods A cross-sectional multicenter study based on a two-round Delphi survey was designed. A total of 98 endocrinologists (mean age 45 years) involved in the care of T2DM patients completed a 43-item questionnaire assessing different aspects of adherence related to CPGs. Results Most participants worked in tertiary care public hospitals. All participants used CPGs, with ADA/EASD as the most common (99%). The lack of time, establishment of an individualized management of patients, insufficient human resources, and therapeutic inertia were scored as the main reasons for not following CPGs recommendations. Participants agreed that insufficient material resources and limitations established by the healthcare system prevent adherence to CPGs. The risk of hypoglycemia was considered to be limiting factor for the patients' integral control. Also, there was consensus on the need to have the support of nursing personnel with specific training in diabetes as well as dietitians and podiatrists. There was disagreement regarding the influence on adherence to CPGs of patient's characteristics not matching those of CPGs, patient's preferences, tolerability of the action recommended, concomitant comorbidities, or pluripathological conditions. Differences according to the participant's age (≤40 years vs. >40 years) were not found. Therapeutic inertia and lack of time did not show a significant correlation. Conclusions Nonadherence to CPGs on T2DM is a multifactorial problem but the existence multiple CPGs, the lack of time, the therapeutic inertia, and insufficient human resources have been identified as factors limiting adherence. Hypoglycemia continues to be a barrier for achievement of targets recommended by CPGs.

The very low risk of myocarditis and pericarditis after mRNA COVID-19 vaccination should not discourage vaccination.

The benefits of vaccination - regarding COVID-19 infection and transmission, as well as COVID-associated complications - clearly outweigh the potential risk of vaccine-associated inflammation of the heart and other adverse events. Given the current state of knowledge, the outcome of myocarditis and pericarditis following vaccination is generally good. This review aims to guide physicians in the early diagnosis and management of suspected myocarditis following mRNA COVID vaccination. The initial work-up should include detailed history, a 12-lead electrocardiogram and serological biomarkers (high-sensitivity cardiac troponin T/I, natriuretic peptides and markers of inflammation) in accordance with the assessments recommended in current clinical practice guidelines for patients presenting with acute chest pain. In patients with suspected myocarditis, further assessment with transthoracic echocardiography and cardiovascular magnetic resonance imaging should be undertaken to confirm peri-/myocarditis and to distinguish the findings from other diseases with similar presentation. Patients with mRNA vaccine-associated myocarditis should be followed-up at least once to exclude chronic myocardial inflammation and deterioration of left ventricular ejection fraction. Consultation with an expert such as an immunologist with experience in vaccination regarding further mRNA vaccinations is advised in all patients with mRNA vaccine-associated perimyocarditis. Reporting of mRNA vaccine-associated myocarditis to Swissmedic is mandatory. Cohort studies prospectively follow-up on young adult and paediatric populations following immunisation with an mRNA COVID vaccine to monitor cardiac and immune parameters would generate valuable knowledge to better understand pathogenesis and risk factors for vaccine-associated perimyocarditis.

How can the perceptions of Korean medicine doctors aid clinical practice guidelines for patients with degenerative lumbar spinal stenosis?: a cross-sectional survey

IntroductionThis study aimed to investigate the perception of Korean medicine (KM) doctors regarding the treatment of degenerative lumbar spinal stenosis (LSS) and explore their opinions on the core clinical questions (CQs) of KM clinical practice guidelines (CPGs) for patients with degenerative LSS. MethodsAn online cross-sectional survey distributed via e-mail was conducted in December 2016. The study population included registered KM doctors (KMDs) in South Korea. The e-mail contained 13 questionnaire items regarding the doctors’ demographic characteristics and perceptions of the core CQs that should be addressed in CPGs for patients with degenerative LSS. Descriptive analyses were performed to summarize the data. ResultsA total of 680 KMDs responded to the survey. Kidney qi deficiency was the most commonly used diagnostic name for degenerative LSS. Acupuncture ranked first in the treatment used for degenerative LSS and in the treatment desired to be included in the development of CPG recommendations. Ojeok-san (积散, 積散, Wuji-san, Goshaku-san) was the number one herbal medicine, and 5% bee venom pharmacopuncture was the number one pharmacopuncture technique used for degenerative LSS. Drug therapy was the most selected control treatment considered appropriate to assess treatment effectiveness and safety. Pain relief was the most chosen indicator among the indicators considered reasonable to assess therapeutic effectiveness. ConclusionResults of this study are expected to inform the development of key CQs of the KM standard CPG for degenerative LSS. The involvement of KMDs in the CPG development process can help develop useful and available CPGs.

Surveillance for hepatocellular carcinoma in chronic viral hepatitis: Is it time to personalize it?

Surveillance with abdominal ultrasound with or without alpha-fetoprotein is recommended by clinical practice guidelines for patients who are considered to be at risk of developing hepatocellular carcinoma (HCC), including those with cirrhosis, advanced fibrosis and special subgroups of chronic hepatitis B (CHB). Application of the standard surveillance strategy to all patients with chronic liver disease (CLD) with or without cirrhosis imposes major sustainability and economic burdens on healthcare systems. Thus, a number of HCC risk scores were constructed, mainly from Asian cohorts, to stratify the HCC prediction in patients with CHB. Similarly, even if less than for CHB, a few scoring systems were developed for chronic hepatitis C patients or cirrhotic patients with CLD of different etiologies. Recently, a few newsworthy HCC-risk algorithms were developed for patients with cirrhosis using the combination of serologic HCC markers and clinical parameters. Overall, the HCC risk stratification appears at hand by several validated multiple score systems, but their optimal performance is obtained only in populations who show highly homogenous clinic-pathologic, epidemiologic, etiologic and therapeutic characteristics and this limitation poses a major drawback to their sustainable use in clinical practice. A better understanding of the dynamic process driving the progression from CLD to HCC derived from studies based on molecular approaches and genetics, epigenetics and liquid biopsy will enable the identification of new biomarkers to define the individual risk of HCC in the near future, with the possibility to achieve a real and cost/effective personalization of surveillance.

Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology.

The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI). Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset <24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0-100%), fibrinolysis (18.8%; 0-100%), and no reperfusion therapy (9.0%; 0-75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5-5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8-97.5%) for the performance of reperfusion therapy of all patients with STEMI <12 h and 54.4% (region range 37.1-70.1%) for timely reperfusion. The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Postoperative surveillance after abdominal aortic aneurysm repair

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Postoperative surveillance after abdominal aortic aneurysm repair

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

A research synthesis of quasi and experimental studies about palliative care nursing in Thailand

Objectives The objective of the study was to synthesize existing quantitative evidence on palliative care intervention among patients with various types of illness in Thailand. Methods A synthesis of quasi and experimental studies published between 2010-2020 was conducted. The sample included theses and research articles that focused on nursing therapeutic therapeutic nursing. programs and which utilized a quasi or experimental study design. The main research instrument was a coding sheet developed by the researchers to record characteristics of the studies that met the inclusion criteria. Data were analyzed by frequency and percentage Results The study found seven studies that were included in literature reviews. Of the seven studies, one was classified as level 2.B and other six were classified as level 2.C. The outcomes of these existing nursing therapeutic programs specific focuses of the therapeutic nursing studies were quality of life (2 studies, 28.5%), symptom management in patients with advanced cancer (1 study, 14.3%), measurement of palliative care behavior (1 study, 14.3%), measurement of self-adaptation (1 study, 14.3%), measurement of quality of nursing care (1 study, 14.3%), and perceived symptom distress and quality of care (1 study, 14.3%). There were four types of interventions for caring patients and families during periods of palliative care: structured information programs, concrete nursing care programs, teaching and counseling programs, and family participation programs. Conclusion The findings of this study could be utilized as empirical evidence in developing clinical practice guidelines for patients in need of palliative care related to the patients’ health problems, symptoms, and needs.

Real-World Clinical Management of Patients with Primary Biliary Cholangitis-A Retrospective Multicenter Study from Germany.

Background: Clinical practice guidelines for patients with primary biliary cholangitis (PBC) have been recently revised and implemented for well-established response criteria to standard first-line ursodeoxycholic acid (UDCA) therapy at 12 months after treatment initiation for the early identification of high-risk patients with inadequate treatment responses who may require treatment modification. However, there are only very limited data concerning the real-world clinical management of patients with PBC in Germany. Objective: The aim of this retrospective multicenter study was to evaluate response rates to standard first-line UDCA therapy and subsequent Second-line treatment regimens in a large cohort of well-characterized patients with PBC from 10 independent hepatological referral centers in Germany prior to the introduction of obeticholic acid as a licensed second-line treatment option. Methods: Diagnostic confirmation of PBC, standard first-line UDCA treatment regimens and response rates at 12 months according to Paris-I, Paris-II, and Barcelona criteria, the follow-up cut-off alkaline phosphatase (ALP) ≤ 1.67 × upper limit of normal (ULN) and the normalization of bilirubin (bilirubin ≤ 1 × ULN) were retrospectively examined between June 1986 and March 2017. The management and hitherto applied second-line treatment regimens in patients with an inadequate response to UDCA and subsequent response rates at 12 months were also evaluated. Results: Overall, 480 PBC patients were included in this study. The median UDCA dosage was 13.2 mg UDCA/kg bodyweight (BW)/d. Adequate UDCA treatment response rates according to Paris-I, Paris-II, and Barcelona criteria were observed in 91, 71.3, and 61.3% of patients, respectively. In 83.8% of patients, ALP ≤ 1.67 × ULN were achieved. A total of 116 patients (24.2%) showed an inadequate response to UDCA according to at least one criterion. The diverse second-line treatment regimens applied led to significantly higher response rates according to Paris-II (35 vs. 60%, p = 0.005), Barcelona (13 vs. 34%, p = 0.0005), ALP ≤ 1.67 × ULN and bilirubin ≤ 1 × ULN (52.1 vs. 75%, p = 0.002). The addition of bezafibrates appeared to induce the strongest beneficial effect in this cohort (Paris II: 24 vs. 74%, p = 0.004; Barcelona: 50 vs. 84%, p = 0.046; ALP < 1.67 × ULN and bilirubin ≤ 1 × ULN: 33 vs. 86%, p = 0.001). Conclusion: Our large retrospective multicenter study confirms high response rates following UDCA first-line standard treatment in patients with PBC and highlights the need for close monitoring and early treatment modification in high-risk patients with an insufficient response to UDCA since early treatment modification significantly increases subsequent response rates of these patients.

Reasons for delay in timely administration of adjuvant chemotherapy for patients with stage III colon cancer: a multicentre cohort study from the McGill University Department of Oncology

PurposeAdjuvant chemotherapy within 56 or 84 days following curative resection is globally accepted as the standard of care for stage III colon cancer as it has been associated with improved...

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Screening for an abdominal aortic aneurysm

•High morbidity and mortality associated with abdominal aortic aneurysm (AAA) rupture.•Most effective mechanism to prevent death from rupture is the prevention of rupture itself.•Ultrasound based abdominal screening, in multiple randomized controlled clinical trials,1Cosford P.A. Leng G.C. Screening for abdominal aortic aneurysm.Cochrane Database Syst Rev. 2007; : CD002945PubMed Google Scholar associated with:○40% reduction aneurysm-related mortality○50% reduction in aneurysm rupture•AAA prevalence, growth and rupture are most strongly predicted by smoking history.•First-degree relatives of patients with AAA have approximately 20% likelihood for AAA development. Consider one-time ultrasound screening for AAA in:•Men and women aged 65 to 75 with a history of tobacco use (Grade 1A).•Men and women older than 75 in good health with history of tobacco use and not previously screened (Grade 2C).•First-degree relatives aged 65 to 75 or older than 75 in good health of patients presenting with AAA (Grade 2C).2Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77.e2Abstract Full Text Full Text PDF PubMed Scopus (783) Google Scholar •Lower AAA prevalence in women balanced by estimated fourfold higher rupture rate and quicker progression to rupture than men (Fig).3Ulug P. Powell J.T. Sweeting M.J. Bown M.J. Thompson S.G. Group S.C. Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women.Br J Surg. 2016; 103: 1097-1104Crossref PubMed Scopus (52) Google Scholar•A contemporary review estimates a 1.34% pooled prevalence of AAA in women over age 60 with a history of tobacco use, with evidence suggesting selective screening of women is cost effective beyond a threshold prevalence of 1%.2Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77.e2Abstract Full Text Full Text PDF PubMed Scopus (783) Google Scholar,3Ulug P. Powell J.T. Sweeting M.J. Bown M.J. Thompson S.G. Group S.C. Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women.Br J Surg. 2016; 103: 1097-1104Crossref PubMed Scopus (52) Google Scholar •Despite Medicare SAAAVE Act in 2007, less than 15% of eligible patients undergo AAA screening.•Consider implementing a primary care clinical alert in the electronic health record prompting an order set or mailed screening invitations for patients that meet screening criteria and include in the subsequent ultrasound report a standardized algorithm for further surveillance and management.5Hye R.J. Smith A.E. Wong G.H. Vansomphone S.S. Scott R.D. Kanter M.H. Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program.J Vasc Surg. 2014; 59: 1535-1542Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm

•The optimal timing of abdominal aortic aneurysm (AAA) repair is based on clinical presentation and aneurysm status:○A ruptured AAA requires emergent repair.○A symptomatic, nonruptured aneurysm is best treated urgently.○An asymptomatic AAA can be treated electively after completion of preoperative assessment.•The choice of endovascular or open surgical repair for elective treatment of AAA should be individualized with appropriate consideration of:○Anatomic suitability for endovascular aneurysm repair (EVAR).○Comorbidities and physical fitness.○Life expectancy.○Compliance with postoperative surveillance.○Patient preference. •If anatomically feasible, EVAR is recommended for treatment of a ruptured AAA (grade 1C), with a suggested door-to-intervention time of less than 90 minutes (Good Practice Standard) (Fig).1Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77.e72Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar•Open surgical repair (OSR) should be considered for elective treatment of AAA when:○The aortic anatomy does not meet recommended indications for use for commercially available EVAR devices.○The estimated life expectancy exceeds 10 to 15 years.2Patel R. Sweeting M.J. Powell J.T. Greenhalgh R.M. EVAR trial investigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial.Lancet. 2016; 388: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (539) Google Scholar •Observational studies report short- and mid-term survival benefit for patients with a ruptured AAA treated by EVAR as compared with OSR,3Wang L.J. Locham S. Al-Nouri O. Eagleton M.J. Clouse W.D. Malas M.B. Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: propensity-matched analysis in the Vascular Quality Initiative.J Vasc Surg. 2020; 72: 498-507Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar but caution is required in inferring causality.•The perioperative survival benefit associated with EVAR for ruptured AAA has not been supported by randomized, controlled trials.•EVAR for elective AAA treatment is associated with decreased mortality and morbidity, and faster recovery, but a greater incidence of late reintervention and without a late survival benefit as compared with OSR.4Paravastu S.C. Jayarajasingam R. Cottam R. Palfreyman S.J. Michaels J.A. Thomas S.M. Endovascular repair of abdominal aortic aneurysm.Cochrane Database Syst Rev. 2014; : CD004178PubMed Google Scholar •The implementation of a treatment algorithm for the management of ruptured AAA is associated with a significant decrease in 30-day mortality.5Starnes B.W. Quiroga E. Hutter C. Tran N.T. Hatsukami T. Meissner M. et al.Management of ruptured abdominal aortic aneurysm in the endovascular era.J Vasc Surg. 2010; 51: 9-17Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar•Healthcare systems should consider the implementation of a structured, multidisciplinary triage protocol for the emergent management of ruptured AAA or rapid transfer to an EVAR-capable facility, if there are no contraindications to transfer (Figure). •Several scoring systems claim accurate predictions of thirty day mortality after ruptured AAA.6Hansen S.K. Danaher P.J. Starnes B.W. Hollis Jr., H.W. Garland B.T. Accuracy evaluations of three ruptured abdominal aortic aneurysm mortality risk scores using an independent dataset.J Vasc Surg. 2019; 70: 67-73Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar•The validation of a risk assessment tool to predict treatment futility for ruptured AAA would inform:○Patient-centered communication and shared decision-making.○Cost-effective allocation of healthcare resources.•The Vascular Study Group of Northern New England risk calculator predicts in-hospital mortality after elective AAA repair and has been externally validated.○The Vascular Study Group of Northern New England risk calculator should be implemented routinely to facilitate patient-centered communication and shared decision-making, particularly for those patients with a calculated high mortality risk and limited life expectancy.7Eslami M.H. Rybin D.V. Doros G. Siracuse J.J. Farber A. External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models.J Vasc Surg. 2018; 67: 143-150Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65\u2009years of age: a longitudinal study

BackgroundThe implementation of individual clinical practice guidelines in patients with multimorbidity often results in polypharmacy. Our aim was to analyse medication use according to longitudinal multimorbidity patterns (MP) and determine during a 5-year period (2012–16) which MP are associated with abnormal liver and kidney function in primary care patients over 65 years of age living in Catalonia.MethodsDesign: Longitudinal study (years 2012 to 2016) based on the electronic health records contained in Information System for Research in Primary Care database of the Catalan Institute of Health (SIDIAP). Variables: age, sex, MP, medication and polypharmacy (drug exposure obtained from the Pharmacy Invoice Registry). Medicines were classified in accordance with the Anatomical Therapeutic Chemical Classification System (ATC). Glomerular filtration rate was used to determine abnormal kidney function, and serum levels of alkaline phosphatase, alanine transaminase and gamma-glutamyl transpeptidase were used to diagnose abnormal liver function. Statistics: For medication use in MP, we calculated annual mean packages of each drug in each MP, and observed/expected ratios were obtained by dividing mean packages in the cluster by mean packages of the same drug in the overall population. Logistic regression models were fitted to estimate the association between MP at baseline and abnormal kidney and liver function tests during follow up.ResultsNine hundred sixteen thousand six hundred nineteen patients were included, and 743,827 completed the follow up. We identified one polypharmacy profile per MP, and concluded that the most prescribed drugs in each pattern corresponded to the diseases overrepresented in that specific MP. The median of drugs ranged from 3 (Cluster 1 - Non-Specific) to 8 (Cluster 10 - Multisystem Pattern). Abnormal kidney function was most commonly observed in the Cluster 4 - Cardio-Circulatory and Renal (Odds Ratio [OR] 2.19; Confidence interval [CI] 95% 2.15–2.23) and Cluster 3 - Minority Metabolic Autoimmune-Inflammatory (OR 2.16; CI 95% 2.12–2.20) MP. A higher risk of abnormal liver function was observed in the Cluster 8 - Digestive (OR 3.39; CI 95% 3.30–3.49), and Cluster 4 - Cardio-Circulatory and Renal (OR 1.96; CI 95% 1.91–2.02) MP.ConclusionsA higher risk of abnormal kidney and liver function was observed in specific MP. The long-term characterisation of MP and polypharmacy illustrates the burden of chronic multimorbidity and polypharmacy in the elderly population.