Current Evidence-based Strategies Research Articles

Optimizing Pediatric Traumatic Brain Injury Care in the Emergency Department: A Comprehensive Review of Current Practices and Evidence-Based Strategies

Optimizing Pediatric Traumatic Brain Injury Care in the Emergency Department: A Comprehensive Review of Current Practices and Evidence-Based Strategies

Ziabetus (Prediabetes): A Harbinger of Critical Stage in the Continuum of Glucose Metabolism Disorder: A Review

Background: Prediabetes is a metabolic condition characterized by blood glucose levels higher than normal but below the threshold for diabetes mellitus. It represents a critical stage in the progression towards type 2 diabetes mellitus (T2DM) and is associated with an increased risk of cardiovascular disease and other complications. The two major pathophysiologic defects responsible for losing glucose tolerance are insulin resistance and β-cell glucose insensitivity, both appearing in subjects of Intermediate Hyperglycaemia. In classical literature, Unani physicians have described the initial symptoms and factors leading to the pathology, the risk factors are described in terms of ‘Su-e-mizaj’ as per the concept of Tibb. So, it is considered in the context of Ziabetus which is described as a disease that develops due to Sue-mizaj haar (abnormal hot temperament). The symptoms mentioned in Unani medicine are increased frequency of micturition (ants and flies are attracted to urine), increased thirst, nocturia, dryness of mouth and whole body, fatigue, loss of weight, malaise, and cramps in lower extremities. The modern drug-based approach for the management of Intermediate Hyperglycaemia is associated with inherent drawbacks, including toxicity, tolerability, cost, and efficacy. Objective: The purpose of this review is to provide an in-depth understanding of prediabetes concerning the classical literature of Greek medicine based on the analysis of certain parameters like etiopathophysiology, current diagnostic criteria, risk factors, and evidence-based management strategies. By synthesizing findings from epidemiological studies, and clinical trials, this paper aims to enhance understanding of prediabetes and facilitate effective preventive measures and interventions. Keywords: Prediabetes, Intermediate hyperglycaemia, Impaired Glucose Tolerance, Impaired Fasting Glucose, Insulin Resistance.

Review article: Diagnosis and management of laryngopharyngeal reflux.

Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux. To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux. We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches. We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients. Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.

Acute Subdural Hematoma Management in the Emergency Department

Acute subdural hematoma (ASDH) is a serious and potentially life-threatening condition that requires prompt and effective management in the emergency department (ED). This review article aims to provide an overview of the current evidence-based management strategies for ASDH in the ED setting. The article begins by discussing the pathophysiology of ASDH, emphasizing the rapid accumulation of blood between the dura mater and the arachnoid membrane following a traumatic brain injury. This can lead to increased intracranial pressure and potentially fatal brain herniation if not promptly addressed. The review then outlines the initial assessment and resuscitation of patients with suspected ASDH in the ED. The article then delves into the specific management strategies for ASDH in the ED, including the role of neurosurgical consultation, and the potential need for emergent surgical intervention to evacuate the hematoma and relieve pressure on the brain. In conclusion, this review article provides a comprehensive overview of the current evidence-based management of ASDH in the ED, emphasizing the importance of prompt recognition, accurate diagnosis, and timely intervention to optimize patient outcomes.

Education for Tobacco Use Disorder Treatment: Current State, Evidence, and Unmet Needs.

Tobacco use is undertreated in the medical setting. One driver may be inadequate tobacco use disorder treatment (TUDT) training for clinicians in specialties treating tobacco-dependent patients. We sought to evaluate the current state of TUDT training for diverse professionals and how these skills are assessed in credentialing exams. We performed a focused review of current educational practices, evidence-based strategies, and accreditation exam contents focused on TUDT. Among medical students, participants in reviewed studies reported anywhere from 45 minutes to 3 hours of TUDT training throughout their 4-year programs, most often in the form of didactic sessions. Similarly, little TUDT training was reported at the post-graduate (residency, fellowship, continuing medical education) levels, and reported training was typically delivered as time-based (expected hours of instruction) rather than competency-based (demonstration of mastery) learning. Multiple studies evaluated effective TUDT curricula at varied stages of training. More effective curricula incorporated longitudinal sessions and active learning, such as standardized patient encounters or proctored patient visits. Knowledge of TUDT is minimally evaluated on certification exams. For example, the American Board of Internal Medicine blueprint lists TUDT as <2% of one subtopic on both the internal medicine and pulmonary exams. TUDT training for most clinicians is minimal, does not assess competency, and is minimally evaluated on certification exams. Effective, evidence-based TUDT training incorporating active learning should be integrated into medical education at all levels, with attention paid to inclusion on subsequent certifying exams.

Frailty: future prospectives in rehabilitation medicine.

Modern rehabilitation is based on the International Classification of Functioning, Disability and Health (ICF). We will discuss this Classification process in frailty. Frailty is defined as a condition of reduced functional reserve, a state of vulnerability that involves poor recovery of homeostasis and increased susceptibility to stressor mechanisms, with consequent difficulty in returning to the previous condition of balance. Rehabilitation of frailty is reported in the ICF, although, its consensus is not sufficiently addressed due to its recent identification and the limited available information regarding how it should be formulated. Thus, the aim of the present article is to present the current evidence-based rehabilitation strategies applied in management of frailty.

The COVID-19 Pandemic Increased the Use of Virtual Fellowship Interviews, Reduced Case Volume, and Limited Sideline Coverage Opportunities During Sports Medicine Surgeon Training

As one-year orthopaedic sports medicine fellowships rely heavily on elective cases and sports coverage, the COVID-19 pandemic necessitated fellowship programs to temporarily transition to virtual mediums for fellow education. Early in the pandemic, there was uncertainty as to how programs would address concerns of trainee readiness, adequate education, and accompanying psychological impact. However, with a return to prepandemic elective procedure volumes and sideline sports coverage responsibilities, sports medicine fellowships have regained some of their traditional education opportunities. Moreover, the implementation of novel training resources, including virtual didactics, augmented reality surgical skills labs, and telehealth medicine training are poised to outlast the current public health crisis and further supplement fellowship education. This article seeks to report on current evidence-based strategies and developments across several critical aspects of sports medicine training during the COVID-19 pandemic.

The Code-Centric Nature of Computational Thinking Education: A Review of Trends and Issues in Computational Thinking Education Research

Computational thinking (CT) is being recognized as a critical component of student success in the digital era. Many contend that integrating CT into core curricula is the surest method for providing all students with access to CT. However, the CT community lacks an agreed-upon conceptualization of CT that would facilitate this integration, and little effort has been made to critically analyze and synthesize research on CT/content integration (CTCI). Conflicting CT conceptualizations and little understanding of evidence-based strategies for CTCI could result in significant barriers to increasing students’ access to CT. To address these concerns, we analyzed 80 studies on CT education, focusing on both the CT conceptualizations guiding current CT education research and evidence-based strategies for CTCI. Our review highlights the code-centric nature of CT education and reveals significant gaps in our understanding of CTCI and CT professional development for teachers. Based on these findings, we propose an approach to operationalizing CT that promotes students’ participation in CT, present promising methods for infusing content with CT, and discuss future directions for CT education research.

Implicit Racial Bias Education and Healthcare Students: A Review of Current Practices

Purpose: Racial disparities in health are well-documented, underscoring the need for health equity education for future healthcare professionals. The goal of this literature review was to examine and describe the interventions, strategies, and an overview of the current evidence-based strategies for implicit bias education of future medical providers. Method: Guided by the exploratory question of discovering the ways Physician Assistant and Medical students are being taught about implicit racial (IR) bias, a search was conducted in PubMed, CINAHL, ERIC, and Google Scholar. Search terms reflected keywords about IR bias education strategies with an intervention and outcome, and PA or medical students within the last 10 years. Results: Of the dozens of peer-reviewed articles on this topic, 12 were chosen for inclusion. Despite heterogeneity in the study designs in this review, there is evidence that healthcare professional student’s exhibit implicit racial or ethnic bias. In both quantitative and qualitative measures, students and faculty consistently and overwhelmingly recognize the importance ofeducation on this topic. Conclusions: There are different types of successful strategies implemented for IR bias education. There is limited and inconclusive research evidence about the impact of IR bias on clinical decision-making due to difficulty in measuring this.

Improved Postoperative Outcomes By Utilizing A Comprehensive Perioperative Surgical Site Infection (SSI) Reduction Bundle

Background: Surgical site infections (SSIs) can be attributed to increased patient morbidity and mortality, prolonged hospital stays, and overall increased healthcare costs. The Surgical Care Improvement Project (SCIP) was implemented in 2002 but has made limited impact on SSI rates across our facilities, which has led to the creation of a bundled approach of current evidence-based strategies. Methods: In January 2019, a comprehensive SSI prevention bundle of strategies was implemented across a multihospital health system. The bundle was comprised of 8 interventions focusing on the preoperative, intraoperative, and postoperative continuum of care, and refining documentation in the electronic medical record. From January to September 2019 (preointervention period), data were collected from 7,163 adult inpatient and observation elective patients undergoing colon surgery (COLO), abdominal hysterectomy (HYST), hip arthroplasty (HPRO), knee arthroplasty (KPRO), and cardiac bypass graft (CBGB/CBGC). The preintervention period for SSI standardized infection ratios (SIRs) and retrospective review of process measures was set as January–December 2018 (postintervetnion period). Each process measure had outlined targets along with primary outcome measures of overall SSI SIRs and SIRs for each of the 5 reported procedure categories. SSIs were validated to meet CDC and NHSN surveillance case definitions. Secondary outcomes evaluated included length of stay (LOS), readmission rates, and mortality. Results: Overall SIR for all 5 monitored surgical categories decreased by 5% to 1.131 from January to September 2019, compared to SIR of 1.190 in 2018. Hip and knee arthroplasties demonstrated 40% and 38% reductions after the intervention, respectively. Completion of 7 or 8 interventions of the SSI bundle were correlated with lower readmission rates (P = .0488). When any portion of the bundle was used, this was correlated with shorter LOS (P &lt; .0001). Adherence to standardized antimicrobial prophylaxis was associated with decreased mortality (P = .017), for all 5 surgical categories. Conclusions: With the implementation of a focused SSI reduction bundle, our institution has realized reductions in surgical readmissions, length of stay, and mortality. Additionally, SSI rates in certain procedure categories have shown marked improvement. The initial success of this bundle has garnered development of additional procedure focused supplemental strategies for the future year.Funding: NoneDisclosures: Aarikha D’Souza, Banner Health

Critical Care Considerations in Adult Patients With Influenza-Induced ARDS.

Acute respiratory distress syndrome is a complex respiratory disease that can be induced by influenza virus infection. Critical care providers are uniquely positioned to manage this pathological progression in adult patients through evidence-based practice. Influenza and subsequent acute respiratory distress syndrome are associated with extremely high morbidity and mortality in adult patients in the United States. Although evidence-based medical management strategies can alter the clinical trajectory of acute respiratory distress syndrome and improve outcomes, critical care providers do not always implement these measures. To provide critical care providers with an overview of the pathological progression of influenza-induced acute respiratory distress syndrome and the current evidence-based strategies for management. This article reviews the epidemiology and pathophysiology associated with influenza-induced acute respiratory distress syndrome, the criteria for diagnosis, and the evidence-based medical management.

Body Reprogramming: Reframing the Fibromyalgia narrative and providing an integrative therapeutic model.

We propose a theory known as the Hyland model to help conceptualise Fibromyalgia within a complex adaptive control system. A fundamental assumption is that symptom generating mechanisms are causally connected, forming a network that has emergent properties. An illness narrative has been developed which has a ‘goodness of fit’ with the lived experience of those with Fibromyalgia. The theory guides management within the clinical setting and incorporates current evidence-based therapeutic strategies, within a multi-modal intervention described as ‘Body Reprogramming’. This intervention focuses on non-pharmacological and lifestyle-based considerations. The theoretical framework also helps explain why modest therapeutic effects are gained from current pharmacological options.

Management of Severe Pain in Terminally Ill Patients at Home: An Evidence-Based Strategy.

The purpose of this article is to describe current evidence-based strategies to manage severe pain in patients living with terminal illnesses. A comprehensive pain assessment is a critical step in the initial development of a pain management plan and for ongoing evaluation of patients' pain. Although we have many effective clinical tools available for pain assessment, they are not always used consistently, which can negatively affect the pain management plan. Home care and hospice nurses need to be consistent in using the tools and documenting the patient's pain level and response to the pain management plan. Patients and caregivers have concerns and fears surrounding medication use, particularly with narcotic analgesics. It is vital that nurses provide thorough patient-centered teaching about medications to help address these concerns. Research has found that nurses who also provided validation to patients and families regarding their concerns, followed by education, were the most effective.

Perioperative Acute Care of Older Patients Living with Frailty

Frailty has been independently linked to adverse postoperative outcomes including increased morbidity, mortality, health resource use, and disability. We discuss the data underlying these associations, as well as literature supporting perioperative frailty assessment and perioperative management strategies, with a focus on older people with frailty undergoing elective, non-cardiac surgery. Perioperative interventions tested to improve outcomes for older people with frailty are limited; interventions proven to improve outcomes are even more rare. Current evidence-based strategies include exercise therapy, preoperative identification and communication of frailty status, and multidisciplinary geriatric focused care. No specific intraoperative strategy exists to impact outcomes for people with frailty. Older people with frailty are vulnerable to adverse outcomes following surgery. However, significant knowledge gaps exist with respect to encouraging routine assessment of frailty and development of effective perioperative interventions. Anesthesiologists are uniquely poised to facilitate the multidisciplinary perioperative care of frail patients. High-quality trials are needed to elucidate patient-centered outcomes, risk prediction, shared decision-making, and individualized perioperative interventions in older patients with frailty.

Irritable Bowel Syndrome: Current and Emerging Therapies

Dr. Starkweather is Professor, Center for Advancement in Managing Pain, University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269; E-mail: [email protected]. The purpose of this article is to provide a summary of current evidence-based management strategies for individuals with irritable bowel syndrome.The author, faculty, and staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity.CME AccreditationLippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on August 30, 2021.CNE AccreditationLippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Lippincott Professional Development will award 1.0 contact hours for this continuing nursing education activity. This activity has been assigned 0.5 pharmacology credits. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on September 3, 2021.

Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies.

Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).

CRITICS-II: a multicentre randomised phase II trial of neo-adjuvant chemotherapy followed by surgery versus neo-adjuvant chemotherapy and subsequent chemoradiotherapy followed by surgery versus neo-adjuvant chemoradiotherapy followed by surgery in resectable gastric cancer

BackgroundAlthough radical surgery remains the cornerstone of cure in resectable gastric cancer, survival remains poor. Current evidence-based (neo)adjuvant strategies have shown to improve outcome, including perioperative chemotherapy, postoperative chemoradiotherapy and postoperative chemotherapy. However, these regimens suffer from poor patient compliance, particularly in the postoperative phase of treatment. The CRITICS-II trial aims to optimize preoperative treatment by comparing three treatment regimens: (1) chemotherapy, (2) chemotherapy followed by chemoradiotherapy and (3) chemoradiotherapy.MethodsIn this multicentre phase II non-comparative study, patients with clinical stage IB-IIIC (TNM 8th edition) resectable gastric adenocarcinoma are randomised between: (1) 4 cycles of docetaxel+oxaliplatin+capecitabine (DOC), (2) 2 cycles of DOC followed by chemoradiotherapy (45Gy in combination with weekly paclitaxel and carboplatin) or (3) chemoradiotherapy. Primary endpoint is event-free survival, 1 year after randomisation (events are local and/or regional recurrence or progression, distant recurrence, or death from any cause). Secondary endpoints include: toxicity, surgical outcomes, percentage radical (R0) resections, pathological tumour response, disease recurrence, overall survival, and health related quality of life. Exploratory endpoints include translational studies on predictive and prognostic biomarkers.DiscussionThe aim of this study is to select the most promising among three preoperative treatment arms in patients with resectable gastric adenocarcinoma. This treatment regimen will subsequently be compared with the standard therapy in a phase III trial.Trial registrationclinicaltrials.gov NCT02931890; registered 13 October 2016. Date of first enrolment: 21 December 2017.

Low Malignancy Rates in Fine-Needle Aspiration Cytologies in a Primary Care Setting in Germany.

Reported results for thyroid nodule fine-needle aspiration (FNA) cytology mainly originate from tertiary centers. However, thyroid nodule FNA cytology is mainly performed in primary care settings for which the distribution of FNA Bethesda categories and their respective malignancy rates are largely unknown. Therefore, this study investigated FNA cytology malignancy rates of a large primary care setting to determine to what extent current evidence-based strategies for the malignancy risk stratification of thyroid nodules are applied and applicable in such primary care settings. In a primary care setting, 9460 FNAs of thyroid nodules were retrospectively analyzed from 8380 patients evaluated by one cytologist (I.R.) during a period of two years. The 8380 FNA cytologies were performed by 64 physicians in different private practices throughout Germany in primary care settings. The cytopathologic results were classified according to the Bethesda System as non-diagnostic in 19%, cyst/cystic nodule in 21%, benign (including thyroiditis) in 48%, atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in 6%, follicular neoplasms/suspicious for follicular neoplasm (FN/SFN) in 4%, suspicious for malignancy (SFM) in 1%, and malignant in 1%. The proportion of patients proceeding to surgery or with a follow-up of at least one year and the observed risks of malignancy were 22%/8% for AUS/FLUS, 69%/17% for FN/SFN, 78%/86% for SFM, and 71%/98% for malignant. For 112 cytologically suspicious and malignant FNAs, there were 102 true positives and 10 false positives, considering histology as gold standard. At variance with other data mostly originating from tertiary centers, these data demonstrate low percentages for malignant, SFM, FN/SFN, and AUS/FLUS, and high percentages for cysts/cystic nodules in this primary care setting in Germany. The risks of malignancy for malignant, SFM, AUS/FLUS, and FN/SFN FNA cytologies are according to Bethesda recommendations.

Translational Advances in the Management of Acute Spinal Cord Injury

Translational Advances in the Management of Acute Spinal Cord Injury

Protecting the premature brain: current evidence-based strategies for minimising perinatal brain injury in preterm infants

Improving neurodevelopmental outcome for preterm infants is an important challenge for neonatal medicine. The disruption of normal brain growth and neurological development is a significant consequence of preterm birth and...