Current Practice Guidelines Research Articles

Evaluation of Clinical Practice Guidelines on Fall Prevention and Management for Older Adults

With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have been developed. A systematic evaluation of the recommendations and agreement level is lacking. To perform a systematic review of clinical practice guidelines for falls prevention and management for adults 60 years or older in all settings (eg, community, acute care, and nursing homes), evaluate agreement in recommendations, and identify potential gaps. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical Subject Headings search terms were related to falls, clinical practice guidelines, management and prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three independent reviewers selected records for full-text examination if they followed evidence- and consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation scores, and agreement across topic areas was assessed using the Fleiss κ statistic. Of 11 414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean [SD], 80.1% [5.6%]), although individual quality domain scores for clinical applicability (mean [SD], 63.4% [11.4%]) and stakeholder (clinicians, patients, or caregivers) involvement (mean [SD], 76.3% [9.0%]) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (≥11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations. This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders.

Cellulitis: A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis.

Cellulitis, an infection involving the deep dermis and subcutaneous tissue, is the most common reason for skin-related hospitalization and is seen by clinicians across various disciplines in the inpatient, outpatient, and emergency room settings, but it can present as a diagnostic and therapeutic challenge. Cellulitis is a clinical diagnosis based on the history of present illness and physical examination and lacks a gold standard for diagnosis. Clinical presentation with acute onset of redness, warmth, swelling, and tenderness and pain is typical. However, cellulitis can be difficult to diagnose due to a number of infectious and non-infectious clinical mimickers such as venous stasis dermatitis, contact dermatitis, eczema, lymphedema, and erythema migrans. Microbiological diagnosis is often unobtainable due to poor sensitivity of culture specimens. The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient. Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended.

Abdominal Sepsis - Current Definitions and Practice.

Abdominal sepsis remains the second most common source of sepsis, a life-threatening condition that became a global health priority in the medical field research. Open abdomen is part of the damage control surgery, a life-saving strategy in a well-selected group of surgical patients with severe abdominal sepsis and intra-abdominal hypertension. Definitions and recommendations in the management of abdominal sepsis and open abdomen have gradually evolved, as a reflection of the progress of both the comprehension of physiopathological mechanisms involved in sepsis and the technology of different temporary abdominal closure systems. The aim of this paper is to make an up-to-date literature narrative review of the definitions and current practice guidelines in abdominal sepsis, with illustration of clinical experience in the management of open abdomen wounds. In the past decades, progress has been made in the management of abdominal sepsis, with greatly ameliorated survival rates. Rapid diagnosis, extensive comprehension of the physiopathological mechanisms of sepsis, adapted fluid resuscitation, antimicrobial therapy and damage-control surgery, orchestrated by a multy-disciplinary team, play an equally important role in the prognosis of a patient.

AACE2021-A-1066: Evaluation of Physicians' Approaches for the Management of Patients with Diabetes During Ramadan in Iraq

In Diabetes Mellitus, fasting Ramadan comes with several challenges for both patients and physicians (1). However, majority of Muslims with type 2 diabetes (T2D) fast Ramadan (2). Therefore, several guidelines have been developed to help physicians in managing their patients during Ramadan (1, 3). This survey aims to investigate approaches adopted by Iraqi physicians for the management of diabetes during Ramadan. This was a cross-sectional online survey based study conducted via Google forms from March 20 through March 27, 2021. The participants were specialist doctors from different regions in Iraq who were directly involved in management of people with diabetes mellitus. The Google form was distributed to the intended specialist doctors through an invitation link via emails and WhatsApp groups exclusive for specialist doctors from Iraq. Repeat submissions from the same link were automatically blocked by the survey server. The survey was completely anonymous and participants' confidentiality was maintained throughout the study. A total of 140 responses collected in this study. Majority of the participants were family physicians followed by internal medicine physicians and endocrinologists in the following rates 29.2 %, 27.1 % and 16.4 % respectively. Among the respondents, 94.3% reported giving advice to their patients regarding Ramadan fasting; 84.3% of this advice was based on several factors (Table 1). Those who do not follow a specific guideline in their provision of care and depend on their experience represent 53%. Of them, family physicians were the predominant (70.2%). Pre-Ramadan education is provided by 75% of the participants. Minority (14.3%) allow patients with type 1 diabetes to fast Ramadan and 32.1% allow those with T2D on insulin to fast. Recent DKA and recent severe hypoglycemia were the main causes for not allowing people to fast Ramadan, 79.3% and 74.3% respectively (Table 2). Regarding treatment modification during fasting, 56.4 % of physicians change the frequency of administration. Lastly, 67.8 % scored 7/10 or above in the questions to test the familiarity of physicians with the established international guidelines. This survey highlights the importance of medical education for doctors and the need for structural education programs directed to the family physicians, internists, and other treating physician regarding the current practical guidelines. Health care providers need to be familiar with current diabetes and Ramadan fasting guidelines.

Surgery versus non-operative treatment for ER-stress unstable Weber-B unimalleolar fractures: a study protocol for a prospective randomized non-inferiority (Super-Fin) trial

Roughly two-thirds of ankle fractures are unimalleolar injuries, the Weber B-type fibula fracture being by far the most common type. Depending on the trauma and the accompanying soft-tissue injury, these...

Incremental Velocity Error as a New Treatment in Vestibular Rehabilitation (INVENT VPT) Trial: study protocol for a randomized controlled crossover trial

BackgroundA clinical pattern of damage to the auditory, visual, and vestibular sensorimotor systems, known as multi-sensory impairment, affects roughly 2% of the US population each year. Within the population of US military service members exposed to mild traumatic brain injury (mTBI), 15–44% will develop multi-sensory impairment following a mild traumatic brain injury. In the US civilian population, multi-sensory impairment-related symptoms are also a common sequela of damage to the vestibular system and affect ~ 300–500/100,000 population. Vestibular rehabilitation is recognized as a critical component of the management of multi-sensory impairment. Unfortunately, the current clinical practice guidelines for the delivery of vestibular rehabilitation are not evidence-based and primarily rely on expert opinion. The focus of this trial is gaze stability training, which represents the unique component of vestibular rehabilitation. The aim of the Incremental Velocity Error as a New Treatment in Vestibular Rehabilitation (INVENT VPT) trial is to assess the efficacy of a non-invasive, incremental vestibular adaptation training device for normalizing the response of the vestibulo-ocular reflex.MethodsThe INVENT VPT Trial is a multi-center randomized controlled crossover trial in which military service members with mTBI and civilian patients with vestibular hypofunction are randomized to begin traditional vestibular rehabilitation or incremental vestibular adaptation and then cross over to the alternate intervention after a prescribed washout period. Vestibulo-ocular reflex function and other functional outcomes are measured to identify the best means to improve the delivery of vestibular rehabilitation. We incorporate ecologically valid outcome measures that address the common symptoms experienced in those with vestibular pathology and multi-sensory impairment.DiscussionThe INVENT VPT Trial will directly impact the health care delivery of vestibular rehabilitation in patients suffering from multi-sensory impairment in three critical ways: (1) compare optimized traditional methods of vestibular rehabilitation to a novel device that is hypothesized to improve vestibulo-ocular reflex performance, (2) isolate the ideal dosing of vestibular rehabilitation considering patient burden and compliance rates, and (3) examine whether recovery of the vestibulo-ocular reflex can be predicted in participants with vestibular symptoms.Trial registrationClinicalTrials.gov NCT03846830. Registered on 20 February 2019.

Cancer prevention through cascade genetic testing: A review of the current practice guidelines, barriers to testing and proposed solutions

Cancer prevention through cascade genetic testing: A review of the current practice guidelines, barriers to testing and proposed solutions

PH Professional Network: Genetic Counseling and Pulmonary Arterial Hypertension

PH Professional Network: Genetic Counseling and Pulmonary Arterial Hypertension

Is the Medium Still the Message? Culture-Independent Diagnosis of Gastrointestinal Infections.

Infectious diarrhea is caused by a variety of pathogens, including viruses, bacteria, and parasitic organisms. Though the causative agent of diarrhea has historically been evaluated via stool cultures, recently, culture-independent diagnostic tests (CIDT) have been developed and utilized with increasing frequency. Current practice guidelines recommend their use as adjuncts to stool cultures for diagnosing acute and chronic diarrhea. The three principal CIDT are microscopy, enzyme-based immunoassays (EIAs), and molecular based polymerase chain reaction (PCR). This review explores the common causes of infectious diarrhea, the basics of stool culture, the diagnostic utility of these three culture-independent modalities, and the strengths and weaknesses of all currently available clinical techniques. It also outlines considerations for specific populations including returning travelers and those with inflammatory bowel disease.

Incidence and management of Osgood-Schlatter disease in general practice: retrospective cohort study.

BackgroundOsgood–Schlatter disease (OSD) is a non-traumatic knee problem that is primarily observed in sports-active children and adolescents aged 8–15 years.AimTo determine the incidence of OSD and to gain an insight into the management of children and adolescents with OSD in general practice.Design and settingA retrospective cohort study was conducted using a healthcare database containing full electronic health records of over 200 000 patients in general practice in and around the Dutch city of Rotterdam.MethodPatients with a new diagnosis of OSD from 1 January 2012 to 31 December 2017 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of OSD were manually interpreted.ResultsThe mean incidence over the study period was 3.8 (95% confidence interval [CI] = 3.5 to 4.2) per 1000 person–years in those aged 8–18 years. Boys had a higher incidence rate of 4.9 (95% CI = 4.3 to 5.5) compared with girls (2.7, 95% CI = 2.3 to 3.2). Peak incidence was at 12 years of age for boys and 11 years for girls. Advice was the most commonly applied strategy (55.1%), followed by rest (21.0%), referral for imaging (19.5%), and physiotherapy (13.4%).ConclusionTo the authors’ knowledge, for the first time the incidence of OSD has been calculated using GP electronic medical files. There is a discrepancy, especially for imaging and referral to a medical specialist, between the current Dutch general practice guidelines and how GPs actually manage the condition in clinical practice.

Disclosing Genetic Risk of Alzheimer's Disease to Cognitively Unimpaired Older Adults: Findings from the Study of Knowledge and Reactions to APOE Testing (SOKRATES II).

Current practice guidelines recommend against Apolipoprotein E (APOE) testing. However, advances in Alzheimer's disease (AD) research and care may soon change this. To examine longitudinally the experience of learning an APOE result and, if an ɛ4 carrier, taking a disease-specific treatment to reduce one's risk of AD. Fifty ɛ4 carriers and 20 non-carriers completed semi-structured interviews 3 months and 15 months after APOE disclosure. Individuals generally understand their APOE results. While non-carriers felt relief, ɛ4 carriers often described themselves as disappointed by their result but nevertheless glad to know. Carriers expressed concerns about stigma and discrimination, including in the workplace. Carriers adopted new health behaviors at higher rates than non-carriers and revised their future plans to account for their increased risk of AD. Individuals participating in research were hopeful that their participation would help them or others; individuals who learned they were at increased risk for AD but who could not participate in research were disappointed. Providers disclosing APOE results should be sensitive to how APOE results shape emotions, self-perceptions, and attitudes about memory; raise concerns about stigma and discrimination in personal and professional relationships; influence health behaviors and decision-making; and can have follow-on effects on family members.

Hepatobiliary and Pancreatic: Liver lesions in cirrhosis: When to biopsy?

A 70-year-old man originally from Poland was referred to the hepatoma service for investigation of two liver lesions found during routine hepatocellular carcinoma (HCC) screening. Active medical history included both castrate sensitive metastatic prostate cancer and Child–Pugh A cirrhosis secondary to type 2 diabetes mellitus and previous heavy alcohol use. For his prostate cancer, he was treated with androgen deprivation therapy (ADT) with goserelin and received upfront docetaxel chemotherapy with prednisolone, before being enrolled on a clinical trial of enzalutamide. Prostate specific antigen (PSA) level remained suppressed at <0.01 μg/L on therapy. The patient was asymptomatic with no features of hepatic decompensation. His Child–Pugh status was A6. Biochemistry revealed preserved synthetic liver function; alpha fetoprotein (AFP) level was 5 μg/L. Computed tomography (CT) chest, abdomen, and pelvis demonstrated two 10-mm arterially enhancing hepatic nodules in segments 7/8 and 4a (Fig. 1a) with no portal venous washout (Fig. 1b). On magnetic resonance imaging (MRI) with Primovist, both lesions retained Primovist and hence both were indeterminate (Liver Imaging Reporting and Data System [LI-RADS]-3). Differentials at discussion at the Hepatoma Multidisciplinary meeting included regenerative or dysplastic nodules, given metastatic prostate cancer typically shows hypodensity on contrast-enhanced imaging. The nodules were followed up in tandem with the patient's prostate cancer at 6 monthly intervals and were stable on contrast-enhanced CT (LI-RADS 3) at 12 and 18 months (Fig. 1c) (LI-RADS 3) and therefore did not meet criteria for biopsy. In addition, there were numerous new pulmonary nodules. At 24 months however, CT revealed new lesions concerning for multifocal HCC (Fig. 1d), increase in the size of the segment 7 and 8 lesions with a new 1.5-cm lesion in segment 2 with washout (LI-RADS 5). The patient remained clinically stable and had a suppressed PSA level. He underwent an ultrasound guided biopsy of the segment 2 lesion. Histopathology was consistent with a diagnosis of metastatic small cell neuroendocrine carcinoma. The patient was commenced on single agent Carboplatin to treat his now de-differentiated small cell prostate cancer, to which he has responded well with interval response demonstrated on serial CT of pulmonary and liver lesions in addition to the bony disease on CT SPECT. The diagnosis of HCC is typically made on cross-sectional radiological findings without the need for confirmatory tissue in cirrhotics. LI-RADS scoring system has high sensitivity and specificity in diagnosing HCC in cirrhotic patients and is applicable to lesions ≥ 1 cm. Thus, biopsy is rarely required to diagnose HCC. Current guidelines support the use of the LI-RADS as a classification system for reporting liver lesions. The decision to biopsy is a contentious clinical question that is not definitively answered by current guidelines. Biopsy carries known risks of bleeding, tumor seeding, and failure to obtain adequate tissue for sampling. There are several mimics of HCC on imaging. Intrahepatic cholangiocarcinomas are known to mimic HCC. Tumors such as neuroendocrine tumors, squamous cell carcinoma metastases, and lung cancer metastases require pathological differentiation from HCC. Prostate cancer metastasis to the liver is heralded by hypoenhancement on contrast-enhanced imaging, whereas small cell prostate cancer itself is ill defined in imaging and there is currently a paucity of literature describing its imaging characteristics. It is aggressive in nature and 40–50% of cases are reported to occur in men with pre-existing prostate adenocarcinoma. The PSA is highly sensitive to progression of metastatic prostate adenocarcinoma but not to de-differentiated carcinoma, and it can therefore be difficult to differentiate de-differentiated prostate cancer from HCC in the cirrhotic patient. This case demonstrates that although current clinical practice guidelines deliver a safe approach to the diagnosis of HCC, alternative diagnoses can be missed if they carry similar characteristics on cross-sectional imaging, especially in cirrhotic patients and particularly in those with a cancer history. The role of biopsy in indeterminate liver lesions is often a discussion point and requires multidisciplinary team discussion, and the LI-RADS criteria should always be interpreted in the clinical context.

Evaluation of the Effectiveness and Safety of Alirocumab Use in Statin-Intolerant Veterans.

Since 1987, statin therapy has been the mainstay of treatment for hypercholesterolemia, and current practice guidelines recommend statins as first-line therapy given demonstrated reductions in elevated low-density lipoprotein cholesterol (LDL-C) and cardiovascular (CV) mortality reduction in robust clinical trials. The primary objective of this case series was to assess LDL-C reduction associated with alirocumab use in statin-intolerant veterans at a single US Department of Veterans Affairs medical center. The secondary objective was to assess the incidence of CV events. A retrospective chart review was conducted to identify statin-intolerant veterans who were initiated on treatment with alirocumab for LDL-C and/or CV risk reduction between June 2017 and May 2019. Electronic health records of all eligible patients who received alirocumab were reviewed, and basic demographics (patient age, sex, and race/ethnicity) as well as medical characteristics at baseline were collected. Baseline LDL-C was compared with levels at 4 and 24 weeks. Although a majority of patients saw a significant and clinically meaningful reduction in LDL-C, the group of patients with an increase in LDL-C may have benefitted from targeted intervention to improve medication and dietary adherence. Alirocumab use in 24 statin-intolerant veterans resulted in a significant reduction in LDL-C at 4 and 24 weeks after initiation. Large long-term studies would better evaluate CV benefit associated with alirocumab therapy in a veteran population.

Recurrent VTE in Pregnant Woman with Previous Personal History of VTE: A Systematic Review and Meta-Analysis

Introduction: Venous thromboembolism (VTE) is one of the leading causes of morbidity and mortality during pregnancy and the postpartum periods. Despite that, the prevention and management of VTEs in pregnant patients remains an area of great debate, particularly among those with a personal VTE history. There is no solid evidence behind the current practice guidelines on the prevention of VTE in pregnancy as most data comes from studies focusing on non-pregnant patients or from small studies. It has been suggested that without low molecular weight heparin (LMWH) thromboprophylaxis, women with a personal history of VTE may have a 2% to 10% absolute risk of developing recurrent VTE during a subsequent pregnancy. We conducted a systematic review to evaluate the risk of VTE recurrence during pregnancy for pregnant patients with prior personal history of VTE and the effect of LMWH on such risk.Materials and Methods: MEDLINE and EMBASE were searched between January 2000 to December 2020. We included studies that evaluated pregnant patients with previous personal VTE history (deep vein thrombosis (DVT) and pulmonary embolism (PE) only) that assessed venous thromboembolism recurrence and/or bleeding complication and/or pregnancy outcomes. Study selection and data extraction was conducted by 3 reviewers and discrepancies resolved by consensus. A meta-analysis of proportions was done through a Freeman-Tukey transformation using random effect models. Groups were analyzed according to prophylaxis strategy. Heterogeneity between studies was assessed by Cochrane Q and Higgins I 2 analyses. Publication bias was assessed using Eggers' tests and funnel plot.Results. Of 6934 potential studies, 27 were included in this systematic review. The studies included 3631 pregnant patients with a previous history of DVT or PE, regardless of the presence of thrombophilia. We found a wide variability in thromboprophylaxis practices which included mostly low molecular weight heparin using weight-based, risk category-based, anti-Xa based, fixed, or trimester-adjusted doses . In studies that categorized patients into provoked, estrogen associated and unprovoked, most patients had an estrogen-associated previous VTE.The estimated pooled proportions of VTE recurrence were 2.7% (95% CI 1.8-3.7; I 2 55.5%) in patients who were consistently on anticoagulation during pregnancy (pre- and post-partum), 2.6% (95% CI 0.6-5.9; I 2 not estimable) in patients who received anticoagulation in the postpartum period only, and 25.3% (95% CI 8.9-46.6; I 2 93.2%) in patients who were not on anticoagulation. No comparison could be done on the different dosage strategies due to the limited number of studies and wide variety of strategies. Due to limited data available, bleeding complications and pregnancy outcomes could not be assessed.Conclusion. In patients with a previous VTE history receiving prophylactic anticoagulation (either both pre- and post-partum or post-partum only), the estimates of VTE recurrence were significantly lower than that for patients who did not receive prophylaxis, however, a direct comparison was not possible. The optimal thromboprophylaxis strategy remains unknown. DisclosuresNo relevant conflicts of interest to declare.

An initiative to improve pneumococcal immunization counseling in children with nephrotic syndrome.

BackgroundImmunization is essential in preventing life-threatening pneumococcal infections in children with nephrotic syndrome. An additional 23-valent pneumococcal polysaccharide vaccine (PPSV23) series is required for children with nephrotic syndrome. Despite current practice guidelines, many children with nephrotic syndrome do not receive PPSV23.MethodsOur nephrology clinic conducted a quality improvement project to improve the overall rate of PPSV23 counseling to more than 70% within a 12-month period by applying several targeted interventions to raise providers’ awareness, improve communication with primary care providers, and increase provider adherence. Data was collected from the electronic health record (EHR), and monthly performance was tracked via monthly control charts and overall immunization counseling rate charts.ResultsWe increased adherence to PPSV23 vaccination counseling from a baseline of 12 to 86%. The first intervention that effectively increased the vaccine counseling rate from 12 to 30% was improving a provider’s awareness of the PPSV23 literature and vaccine guidelines. Other interventions included regular performance reviews at division meetings, creating an immunization protocol, posting performance charts on the office bulletin board, and unifying vaccine recommendation templates. Lastly, specific and timely EHR reminders improved the total counseling rate from 52 to 86% and maintained adherence until the completion of the project.ConclusionBridging the knowledge gap in provider awareness and using specific EHR reminders can improve adherence to PPSV23 counseling in children with nephrotic syndrome. Such interventions could be applied to similar groups of immunocompromised patients in whom additional vaccines are indicated.Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information. Supplementary InformationThe online version contains supplementary material available at 10.1007/s00467-021-05305-3.

Recommendations for Managing Adults With Histiocytic Neoplasms: New NCCN Guidelines

The histiocytoses, a group of clonal and reactive conditions, arise from monocytic macrophage or dendritic cell lineages. The current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Histiocytic Neoplasms reflect the most up-to-date, evidence-based data relating to the evaluation and management of this disease. Specifically, the guidelines focus on adult Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease. Because these disorders are rare, challenges have arisen regarding clinical suspicion, histologic diagnosis, treatment, and molecular subtyping. Future versions of the NCCN Guidelines will address the diagnosis and management of pediatric patients, as well as malignant histiocytosis.

Musk Tongxin Dripping Pills for treating Ticagrelor in Patients After Percutaneous Coronary Intervention: Echocardiography Combined with Untargeted Metabolomics.

Objectives: As current clinical practice guidelines, ticagrelor is the suggested therapeutic scheme to prevent adverse cardiovascular events in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI) treatment. However, this therapeutic strategy still fails, and around 30% patients display inadequate antiplatelet responses. Musk Tongxin Dripping Pill (MTDP) in Chinese hospital was usually considered as the combination with ticagrelor to improve the treatment effect. Unfortunately, the mechanism has not been elucidated. Methods: The untargeted metabolomic method was introduced based on liquid chromatography–high-resolution mass spectrometry (HPLC-HRMS) coupled with STI for the research of the drug combination mechanism between ticagrelor and MTDP. 28 patients with a confirmed diagnosis of AMI were selectively collected, who were then divided into two different dosage regimen groups, and the serum samples were collected for the untargeted metabolomics assay. Then the differential metabolites were associated with blood biochemical indicators. Results: The GLS values in both groups increased after treatment and those in the ticagrelor and MTDP combination group after treatment were higher than those in the ticagrelor group (p < 0.05), suggesting that the combination medication has better therapeutic effect on patients with myocardial infarction. From metabolomics analysis, the species of metabolites changed in two groups before and after treatment. Moreover, 93 differential metabolites changed in the drug combination group compared with the ticagrelor group after treatment (p < 0.05), which mainly related to changes in fatty acid metabolism pathways. Then the differential metabolites were found to be related with blood biochemical indicators, such as lipid, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Conclusion: This work will provide a possible mechanism of the drug combination interaction between ticagrelor and MTDP from two angles of echocardiography and metabonomics. Several potential metabolic pathways were also found to have a relationship with MTDP, which will provide a new perspective in clinical medication.

Methods Used to Generate Consensus Statements for Clinical Practice Guidelines: A Primer for the Spine Surgeon.

This was a research methodology study. This review discusses the most commonly utilized consensus group methodologies for formulating clinical practice guidelines and current methods for accessing rigorous up-to-date clinical practice guidelines. In recent years, clinical practice guidelines for the management of several conditions of the spine have emerged to provide clinicians with evidence-based best-practices. Many of these guidelines are used routinely by administrators, payers, and providers to determine the high-quality and cost-effective surgical practices. Most of these guidelines are formulated by consensus groups, which employ methodologies that are unfamiliar to most clinicians. An extensive literature review was performed. The literature was then summarized in accordance with the authors' clinical experience. The Nominal Group Technique, Delphi method, and RAND-UCLA Appropriateness Model are 3 commonly utilized consensus group methodologies employed in the creation of clinical practice guidelines. Each of these methodologies has inherent advantages and disadvantages, is dependent on rigorously performed systematic reviews and meta-analyses to inform the panel of experts, and can be used to answer challenging clinical questions that remain unanswered due to a paucity of class I evidence. This review highlights the most commonly utilized consensus group methodologies and informs spine surgeons regarding options to access current clinical practice guidelines. Level V.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain.

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

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.