Current Treatment Practices Research Articles

Autoimmune Pancreatitis and Immunoglobulin G4-related Sclerosing Cholangitis: Past, Present, and Future.

The emergence of glucocorticoid-responsive autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-SC), a new disease entity, has attracted considerable interest within the international gastroenterology community. The typical manifestations of AIP/IgG4-SC are obstructive jaundice and pancreatic enlargement in the elderly, which may mimic the presentations of pancreatobiliary malignancies. The timely diagnosis of AIP/IgG4-SC can lead to adequate glucocorticoid treatment, whereas a misdiagnosis can result in unnecessary major surgery. The diagnostic criteria used to diagnose AIP include several cardinal features of AIP that can be detected via pancreatic parenchymal imaging, ductal imaging, serum IgG4 levels, histopathology, other organ involvement, and response to glucocorticoid therapy. The differential diagnosis of AIP/IgG4-SC may include pancreatobiliary malignancies and primary sclerosing cholangitis. Although most patients with AIP/IgG4-SC respond well to glucocorticoid therapy, there is a frequent relapse of the disease in the long term. This review describes the evolution of the concept of AIP and IgG4-related disease, including the development of diagnostic criteria, discusses the current practice for diagnosis and treatment, and suggests prospects for research.

Optimizing the Choice for Adjuvant Chemotherapy in Gastric Cancer.

Simple SummaryGastric cancer is the fourth largest cause of tumor-related death worldwide. Despite advances in the management of resectable cancer and improvements in early diagnosis, especially in east Asia where screening campaigns are actively performed, many patients experience recurrence and die because of the disease. Adjuvant systemic chemotherapy is administered after radical surgery in order to reduce the risk of recurrence and death. The modality of administration and regimens of chemotherapy in this setting are different between Eastern and Western countries. In Asia, adjuvant chemotherapy is traditionally given after surgery, while in Europe it is commonly scheduled after preoperative chemotherapy and surgery (perioperative chemotherapy), and in Northern America it is usually combined with radiotherapy (chemoradiotherapy). All these approaches are sustained by well-designed phase III clinical studies, and none may be considered superior to the others in the absence of head-to-head comparisons. The identification of predictive and/or prognostic factors could help to select patients at higher risk of recurrence and those more likely to receive a benefit from the adjuvant treatment. This would allow clinicians to avoid the administration of undue toxicity to non-responder patients and even to reduce the cost of unnecessary treatment.Advances in the management of gastric cancer have improved patient survival in the last decade. Nonetheless, the number of patients relapsing and dying after a diagnosis of localized gastric cancer is still too high, even in early stages (10% in stage I). Adjuvant systemic chemotherapy has been proven to significantly improve outcomes. In the present article we have critically reviewed the clinical trials that guide the current clinical practice in the adjuvant treatment of patients affected by resectable gastric cancer, focusing on the different approaches worldwide, i.e., adjuvant chemotherapy, adjuvant chemoradiotherapy, and perioperative chemotherapy. We also delineate the clinical–pathological characteristics that are commonly taken into account to identify patients at a higher risk of recurrence and requiring adjuvant chemotherapy, and also describe novel biomarkers and therapeutic agents that might allow personalization of the treatment.

Ambulatory Pathway for the Management of Superficial Abscesses: Criteria for Safe Provision of Care.

BackgroundSuperficial abscesses are common surgical emergencies and unless complicated, are considered a low-priority emergency often leading to delayed primary treatment. Patients who are clinically stable benefit more from an ambulatory-care approach to their treatment.Aim of studyThis is a retrospective study to investigate the current practice of treatment of superficial abscesses at West Suffolk Hospital, United Kingdom, and evaluate the potential impact of implementing care via the ambulatory pathway to improve patients' experience, optimise the use of hospital resources and identify areas for service improvement.Patients and methodsA total of 76 patients who required inpatient care for drainage of their superficial abscess under general anaesthesia over six months were a part of the study. Admission, procedure, and hospital stay characteristics were evaluated as well as our proposed superficial abscess ambulatory-care pathway (SAAP) criteria.ResultsThe mean age was 39 ± 18 years. Perianal and pilonidal abscesses accounted for 53% of the procedures. Only 24% of the patients had a C-reactive protein (CRP) >100 at admission. The average waiting time before intervention was 19 hours (± 16.25) with patients spending two days on average in the hospital for a procedure that lasted an average of 31 minutes. Overall, 39.5% of the patients received drainage of their abscess on the same day of presentation to the hospital with only five discharges on the same day of admission. Of the total patients, 52.6% met our SAAP criteria for ambulatory care and could have avoided inpatient care and benefitted from same-day discharges.ConclusionAmbulatory care of a superficial abscess is a safe, feasible approach. We recommend establishing an ambulatory care pathway for the management of superficial abscess cases with our SAAP criteria serving as a useful objective guide for effective and safe triage of patients with reduced hospital stay and more efficient utilisation of resources.

Waiting Lists for Psychotherapy and Provider Attitudes Toward Low-Intensity Treatments as Potential Interventions: Survey Study.

BackgroundCommon mental disorders, including depression and anxiety, are leading causes of disability worldwide. Digital mental health interventions, such as web-based self-help and other low-intensity treatments (LITs) that are not digital (eg, bibliotherapy), have the potential to reach many individuals by circumventing common barriers present in traditional mental health care. It is unclear how often LITs are used in clinical practice, or whether providers would be interested in their use for treatment waiting lists.ObjectiveThe aims of this study were to (1) describe current practices for treatment waiting lists, (2) describe providers’ attitudes toward digital and nondigital LITs for patients on a waiting list, and (3) explore providers’ willingness to use digital and nondigital LITs and their decisions to learn about them.MethodsWe surveyed 141 practicing mental health care providers (eg, therapists and psychologists) and provided an opportunity for them to learn about LITs.ResultsMost participants reported keeping a waiting list. Few participants reported currently recommending digital or nondigital LITs, though most were willing to use at least one for patients on their waiting list. Attitudes toward digital and nondigital LITs were neutral to positive. Guided digital and nondigital LITs were generally perceived to be more effective but less accessible, and unguided interventions were perceived to be less effective but more accessible. Most participants selected to access additional information on LITs, with the most popular being web-based self-help.ConclusionsResults suggest providers are currently not recommending LITs for patients on treatment waiting lists but would be willing to recommend them. Future work should explore barriers and facilitators to implementing digital and nondigital LITs for patients on treatment waiting lists.

Advances in vitiligo: Update on therapeutic targets.

Vitiligo, whose treatment remains a serious concern and challenge, is an autoimmune skin disease characterized by patches of depigmentation. The increasing application of molecular-targeted therapy in skin diseases, such as psoriasis and systemic lupus erythematosus, has dramatically improved their condition. Besides, there is a favorable effect of repigmentation in the treatment of the above diseases combined with vitiligo, implying that molecular-targeted therapy may also have utility in vitiligo treatment. Recently, the role of cytokine and signaling pathways in vitiligo pathogenesis are increasingly recognized. Thus, investigations are underway targeting the molecules described above. In this paper, we present a synopsis of current practices in vitiligo treatment and introduce the improvement in identifying new molecular targets and applying molecular-targeted therapies, including those under development in vitiligo treatment, providing valuable insight into establishing further precision medicine for vitiligo patients.

Incidence of hepatocellular carcinoma in chronic hepatitis B virus infection in those not meeting criteria for antiviral therapy.

Chronic hepatitis B virus (HBV) infection is the leading risk factor for hepatocellular carcinoma (HCC). The aim of this study was to explore the incidence of HCC in a cohort of subjects with HBV and correlate with HBV treatment current guidance. We identified 2846 subjects with HBV over the study period. HCC was diagnosed in 386 of 2846 (14%) subjects; 209 of 386 (54%) were on nucleos(t)ide analogue (NA) therapy at time of HCC diagnosis, and 177 of 386 (46%) were not on NA therapy. Of the 177 subjects not on NAs who developed HCC during follow‐up, 153 of 177 (86%) had cirrhosis. Within the 177 subjects not on NAs, 158 of 177 (89%) had undetectable HBV DNA, 10 of 177 (6%) had detectable HBV DNA < 2000 IU/L, and 9 of 177 (5%) had HBV DNA > 2000 IU/L. Of those with cirrhosis and undetectable HBV DNA, 115 of 141 had compensated cirrhosis, and 26 of 141 had decompensated cirrhosis. Significant predictors of HCC on time to event analysis included cirrhosis (hazard ratio [HR] 10, 95% confidence interval [CI] 5.8–17.5; p < 0.001), alanine aminotransferase level (HR 1.004, 95% CI 1.002–1.006; p < 0.001), age (HR 1.04, 95% CI 1.03–1.06; p < 0.001), (HR 1.9, 95% CI 1.2–3.1; p 0.007), and nonalcoholic fatty liver disease (HR 1.7, 95% CI 1.1–2.8; p 0.02). Kaplan–Meier analysis demonstrated the cumulative incidence of HCC in subjects with compensated cirrhosis receiving NA therapy was significantly lower compared to subjects with compensated cirrhosis outside current HBV treatment practice guidance (undetectable HBV DNA) (32% vs. 51%; p < 0.001). Conclusion: Those with untreated compensated cirrhosis with undetectable HBV DNA who do not meet current guidance for treatment had higher rates of HCC than those with compensated cirrhosis and suppressed HBV DNA by NA therapy. This study highlights the need for earlier diagnosis and treatment of HBV.

Produced Water Treatment: Review of Technological Advancement in Hydrocarbon Recovery Processes, Well Stimulation, and Permanent Disposal Wells

Summary Produced water (PW) is the most significant waste product in oil and gas exploitation, and numerous challenges are associated with its treatment. For over half a century, PW treatment and handling have evolved from a waste product to a reusable stream for the petroleum industry. PW is reused and recycled for hydrocarbon recovery processes, well completion, stimulation, drilling, etc. Despite this usage, enormous volumes are still required to be disposed of in the subsurface aquifers or surface water bodies after treatment. Challenges to PW treatment are related mainly to widely varying PW characteristics, nonuniformity of water treatment systems for different fields, and difficulty in designing novel technology due to changing production rates and other design parameters. This paper focuses on purpose-specific water treatment units used in various activities within the oil and gas industries and technological advancement. A detailed account of the historical development of current water treatment practices, disposal, available technology, and challenges in implementation are presented. Forward-looking recommendations are given on how emerging technologies can be integrated into everyday oil and gas activities to achieve the purpose-specific treatment goal.

TreatmentPatterns: An R package to facilitate the standardized development and analysis of treatment patterns across disease domains

Background and objectivesThere is an increasing interest to use real-world data to illustrate how patients with specific medical conditions are treated in real life. Insight in the current treatment practices helps to improve and tailor patient care, but is often held back by a lack of data interoperability and a high-level of required resources. We aimed to provide an easy tool that overcomes these barriers to support the standardized development and analysis of treatment patterns for a wide variety of medical conditions. MethodsWe formally defined the process of constructing treatment pathways and implemented this in an open-source R package TreatmentPatterns (https://github.com/mi-erasmusmc/TreatmentPatterns) to enable a reproducible and timely analysis of treatment patterns. ResultsThe developed package supports the analysis of treatment patterns of a study population of interest. We demonstrate the functionality of the package by analyzing the treatment patterns of three common chronic diseases (type II diabetes mellitus, hypertension, and depression) in the Dutch Integrated Primary Care Information (IPCI) database. ConclusionTreatmentPatterns is a tool to make the analysis of treatment patterns more accessible, more standardized, and more interpretation friendly. We hope it thereby contributes to the accumulation of knowledge on real-world treatment patterns across disease domains. We encourage researchers to further adjust and add custom analysis to the R package based on their research needs.

Management of community-acquired pneumonia in adults with type 2 diabetes mellitus in a multidisciplinary hospital

Community-acquired pneumonia (CAP) is a common acute infectious disease in adults. Diabetes mellitus (DM) increases the incidence of CAP and worsens the prognosis. In this regard, the assessment of the current practice of CAP management in patients with concomitant DM and its compliance with clinical guidelines is of great interest.Purpose. To study the current practice of CAP treatment in adult patients with concomitant type 2 DM in a multidisciplinary hospital and evaluate its compliance with the national clinical guidelines.Methods. A cross-sectional observational study was carried out in a pulmonology department of a republican clinical hospital. The study recruited adult patients with a confirmed diagnosis of CAP and previously diagnosed type 2 DM. For each case, demographic characteristics, the severity of CAP, the presence and nature of complications, systemic antibiotic therapy (ABT) and compliance with 16 quality indicators (QI) were recorded. The quality indicators described the adequacy of examination, treatment and secondary prevention of CAP in the presence of concomitant DM. QIs were chosen based on the national clinical guidelines for CAP and algorithms for specialized medical care for patients with DM.Results. Altogether, 48 patients with the average age of 63.9 ± 10.5 years were enrolled. 81% of patients had mild CAP. The severity criteria were assessed in 60% of the patients, prognosis – in 17% of the patients. X-ray examination, pulse oximetry and complete blood count were performed on time in 100% of the cases. A total of 19% of patients had a culture of respiratory specimens. A blood culture was performed in 11,11% of the cases of severe CAP (SCAP). Rapid urine tests for pneumococcal and legionella antigens have not been used. Glycemia was monitored daily in 27% of the patients. ABT was initiated on time in 100% of the patients.Conclusion. Low adherence to many QIs, insufficient control of glycemia and correction of sugar-lowering therapy in the treatment of hospitalized patients with CAP and concomitant type 2 DM were observed, which can worsen clinical outcomes.

A Global Survey on Diagnostic, Therapeutic and Preventive Strategies in Intensive Care Unit-Acquired Weakness.

Background and Objectives: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent neuromuscular complications in critically ill patients. We conducted a global survey to evaluate the current practices of diagnostics, treatment and prevention in patients with ICU-AW. Materials and Methods: A pre-survey was created with international experts. After revision, the final survey was endorsed by the European Society of Intensive Care Medicine (ESICM) using the online platform SurveyMonkey®. In 27 items, we addressed strategies of diagnostics, therapy and prevention. An invitation link was sent by email to all ESICM members. Furthermore, the survey was available on the ESICM homepage. Results: A total of 154 healthcare professionals from 39 countries participated in the survey. An ICU-AW screening protocol was used by 20% (28/140) of participants. Forty-four percent (62/141) of all participants reported performing routine screening for ICU-AW, using clinical examination as the method of choice (124/141, 87.9%). Almost 63% (84/134) of the participants reported using current treatment strategies for patients with ICU-AW. The use of treatment and prevention strategies differed between intensivists and non-intensivists regarding the reduction in sedatives (80.0% vs. 52.6%, p = 0.002), neuromuscular blocking agents (76.4% vs. 50%, p = 0.004), corticosteroids (69.1% vs. 37.2%, p < 0.001) and glycemic control regimes (50.9% vs. 23.1%, p = 0.002). Mobilization and physical activity are the most frequently reported treatment strategies for ICU-AW (111/134, 82.9%). The availability of physiotherapists (92/134, 68.7%) and the lack of knowledge about ICU-AW within the medical team (83/134, 61.9%) were the main obstacles to the implementation of the strategies. The necessity to develop guidelines for the screening, diagnosing, treatment and prevention of ICU-AW was recognized by 95% (127/133) of participants. Conclusions: A great heterogeneity regarding diagnostics, treatment and prevention of ICU-AW was reported internationally. Comprehensive guidelines with evidence-based recommendations for ICU-AW management are needed.

Current diagnosis and treatment practice of central retinal artery occlusion: results from a survey among German stroke units

BackgroundCentral retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency whose optimal management is still under debate and due to the absence of definite guidelines, practice is expected to vary. We aimed to characterize early evaluation as well as acute treatment and diagnostic approaches in German hospitals with a stroke unit (SU).MethodsIn 07/2021, all 335 certified German SUs were invited to participate in an anonymous online survey endorsed by the German Stroke Society on emergency department care organization, diagnostic procedures, and treatment of patients with unilateral vision loss (UVL) subsequently diagnosed with CRAO.ResultsOne hundred and sixty-three (48.6%) of the 335 eligible centers responded. Most (117/135; 86.7%) stated that UVL patients were treated as an emergency, in 62/138 (44.9%) hospitals according to specific guidelines. First-line evaluation was performed by neurologists in 85/136 (62.5%) hospitals, by ophthalmologists in 43/136 (31.6%) hospitals. Seventy of 135 (51.9%) respondents indicated a lack of on-site ophthalmological expertise. Seventy-four of 129 (57.4%) respondents performed thrombolysis in CRAO and 92/97 (94.8%) stated that patients with CRAO–if admitted to neurology–were treated on a SU.ConclusionsOur findings reflect notable heterogeneity in early intrahospital care of CRAO in German SUs but demonstrate a preference for work-up and management as acute stroke by the involved neurologists. Streamlining interdisciplinary emergency evaluation is essential for ongoing and future prospective trials.

Current treatment practice of functional abdominal pain disorders in children: A multicenter survey

BackgroundApproximately 90% of the children with chronic abdominal pain are diagnosed as having functional abdominal pain disorder (FAPD). The Dutch guideline “functional abdominal pain” provides a stepwise approach to treat FAPD. The aim of this survey was twofold first, to determine adherence to the Dutch guideline, and second to determine current management of FAPDs in clinical practice.MethodsA multicenter survey was designed. The survey was sent to pediatricians and pediatric residents in December 2020. The study ran from October 2020 until March 2021. Participants in ten hospitals in the western region of The Netherlands were invited to complete this survey. Respondents who indicated not to treat children with FAPDs or respondents who completed less than 3 steps of the survey were excluded.ResultsIn total, 85/174 (48.9%) respondents completed the survey. We included 80 respondents, 68 pediatricians and 12 pediatric residents, for analysis. Overall, self-reported guideline adherence was 85%. Self-reported adherence was higher than actual adherence. Only 50% of all respondents followed the first three steps of the guideline. The reported non-pharmacological and pharmacological treatments were diverse and varied between different age groups. The average follow-up duration was between 2 and 6 months, and the most regularly used outcome measures were attendance at school, quality of life, and adequate pain relief/reassurance.ConclusionWe reportedly observed a large variation in the management of children with FAPDs, due to low guideline adherence among clinicians. Improved guideline adherence may be accomplished by updating the guideline with specific recommendations per subtype, follow-up and outcome measures as well measures to improve guideline implementation.

Current Presurgical Infant Orthopedics Practices Among American Cleft Palate Association-Approved Cleft Teams in North America.

Presurgical infant orthopedic (PSIO) therapy has evolved in both its popularity and focus of treatment since its advent. Nasoalveolar molding, nasal elevators, the Latham appliance, lip taping, and passive plates are the modern treatment options offered by cleft teams. Many cleft surgeons also employ postsurgical nasal stenting (PSNS) after the primary lip repair procedure. The purpose of this study is to examine trends in current PSIO care as well as PSNS for the management of patients with cleft lip and palate. An electronic survey was distributed to cleft team coordinators listed by the American Cleft Palate Association. The survey reported on team setting, provider availability, PSIO offerings, contraindications, and use of PSNS. Descriptive statistics and analyses were performed using MS Excel and SPSS. A total of 102 survey responses were received. The majority of settings were children's specialty hospitals (66%) or university hospitals (27%). Presurgical infant orthopedics was offered by 86% of cleft teams, and the majority of those (68%) provided nasoalveolar molding. Nasal elevators and lip taping are offered at 44% and 53% of centers, respectively. Latham and passive plates are both offered at 5.5% of centers. Most centers had an orthodontist providing treatment. The majority of centers use PSNS (86%). Nasoalveolar molding is the most popular PSIO technique in North American cleft centers followed by the nasal elevator, suggesting that the nasal molding component of PSIO is of critical influence on current treatment practices.

Natural course of Guillain-Barré syndrome.

In this retrospective study based on a registry, Kalita et al. [1] compared the outcomes of 189 patients with Guillain-Barré syndrome (GBS) who received intravenous immunoglobulin (IVIg), with 199 age- and peak disability-matched patients who did not receive any immunomodulation or plasmapheresis, thus representing the natural course of GBS. Numbers for in-hospital deaths and poor recovery at 3 months were similar between the two groups. At 6 months, 8.3% of the natural course subgroup, but only 2.2% of the IVIg group, had a poor outcome. After the patients had been divided into those with the acute motor axonal neuropathy (AMAN) phenotype and the acute inflammatory demyelinating polyradiculoneuropathy (AIDP) phenotype, only those with the AIDP phenotype had a better 6-month outcome with IVIg. This study could not have been done in any setting where IVIg or plasmapheresis, the two established treatment modalities for GBS, are readily available. In fact, no clinical trial in GBS with a placebo arm would receive an ethics commission's approval for being carried out. Thus, data like the ones presented in this study are very valuable for our understanding of GBS treatment. The International Guillain-Barré Syndrome Outcome Study (IGOS) is collecting data on GBS patients around the world in a registry. Thus, here is another chance to compare outcomes of patients with and without immunomodulatory treatment. In one report from the IGOS group on current practice of GBS treatment, 193 patients from Bangladesh were excluded from the analysis, because 83% of them were not treated [2]. A study from Bangladesh reported a high mortality (12%) in GBS patients [3]. This was mainly due to lack of ventilator support. In this cohort, 71% of patients are reported as not receiving treatment. Lack of treatment was not a risk factor for mortality; however, the type of treatment is not specified in the report. Together, these data support the notion that intensive care support is more crucial for the survival of GBS patients than the immunomodulatory treatment [4]. We need to consider that the natural course subgroup in the study by Kalita et al. did not renounce treatment out of their free will or for medical reasons. The mere reason was that these patients could not afford the treatment. The group for natural course was matched to the IVIg group by the authors according to age and peak disability. Thus, any questions on whether disability did, in the end, influence the decision on treatment cannot be answered by the present study. However, the authors might further analyze their registry for this question. Claudia Sommer: Conceptualization (equal); writing – original draft (equal); writing – review and editing (equal). Open Access funding enabled and organized by Projekt DEAL. C.S. is a member of the International Guillain-Barré syndrome Outcome Study (IGOS) consortium. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Current clinical practice in antibiotic treatment of Staphylococcus aureus bacteraemia: results from a survey in five European countries.

To determine clinical practice variation and identify knowledge gaps in antibiotic treatment of Staphylococcus aureus bacteraemia (SAB). A web-based survey with questions addressing antibiotic treatment of SAB was distributed through the ESGAP network among infectious disease specialists, clinical microbiologists and internists in Croatia, France, Greece, the Netherlands and the UK between July 2021 and November 2021. A total number of 1687 respondents opened the survey link, of whom 677 (40%) answered at least one question. For MSSA and MRSA bacteraemia, 98% and 94% preferred initial monotherapy, respectively. In patients with SAB and non-removable infected prosthetic material, between 80% and 90% would use rifampicin as part of the treatment. For bone and joint infections, 65%-77% of respondents would consider oral step-down therapy, but for endovascular infections only 12%-32% would. Respondents recommended widely varying treatment durations for SAB with different foci of infection. Overall, 48% stated they used 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) to guide antibiotic treatment duration. Persistent bacteraemia was the only risk factor for complicated SAB that would prompt a majority to extend treatment from 2 to 4-6 weeks. This survey in five European countries shows considerable clinical practice variation between and within countries in the antibiotic management of SAB, in particular regarding oral step-down therapy, choice of oral antibiotic agents, treatment duration and use of 18F-FDG-PET/CT. Physicians use varying criteria for treatment decisions, as evidence from clinical trials is often lacking. These areas of practice variation could be used to prioritize future studies for further improvement of SAB care.

Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery

BACKGROUNDDegenerative spondylolisthesis (DS) is one of the most common pathologies spine surgeons treat. While a number of potential factors have been identified, there is no current consensus on which variables most impact the decision to fuse vs. decompress alone in this population. PURPOSEThe purpose of this study was to describe current DS treatment practices and identify both the radiographic and clinical factors leading to the decision to fuse segments for one level DS. STUDY DESIGN/SETTINGDescriptive cross-sectional survey. PATIENT SAMPLESurveys were administered to members of Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery. OUTCOME MEASURESSurgeon demographics and treatment practices were reported. Radiographic and clinical parameters were ranked by each surgeon with regards to their importance. METHODSThe primary analysis was limited to completed surveys. Baseline characteristics were summarized. Clinical and radiographic parameters were ranked and compared. Ranking of each clinical and radiographic parameters was reported using best and worst rank, mean rank position, and percentiles. The most important, top 3 most important, and top 5 most important parameters were ordered given each parameter's ranking frequency. RESULTS381 surveys were returned completed. With regards to fusion vs. decompression, 19.9% fuse all cases, 39.1% fuse > 75%, 17.8% fuse 50%–75%, and 23.2% fuse <25%. The most common decompressive technique was a partial laminotomy (51.4%), followed by full laminectomy (28.9%). 82.2% of respondents instrument all fusion cases. Instability (93.2%), spondylolisthesis grade (59.8%), and laterolisthesis (37.3%) were the most common radiographic factors impacting the decision to fuse. With regards to the clinical factors leading to fusion, mechanical low back pain (83.2%), activity level (58.3%), and neurogenic claudication (42.8%) were the top 3 clinical parameters. CONCLUSIONSThere is little consensus on the treatment of DS, with society members showing substantial variation in treatment patterns with the majority utilizing fusion for treatment. The most common radiographic parameters impacting treatment are instability, spondylolisthesis grade, and laterolisthesis while mechanical low back pain, activity level, and neurogenic claudication are the most common clinical parameters.

Patient-tailored reproductive health care.

Patient-tailored reproductive health care represents an important challenge for the current practice of infertility prevention, diagnosis and treatment. This approach is based on the concept of precision medicine, taking into account genetic, epigenetic, metabolic and lifestyle characteristics of each individual patient. Even though this goal is still far from being wholly achieved, some aspects can already be put into practice nowadays. Personalization can be based on a comprehensive analysis and synthesis of the patients' personal and familial history, taking into account outcomes of previous assisted reproduction technique (ART) attempts, if available, and confronting these data with the past and the latest clinical and laboratory examination outcomes. As to the male fertility status, there is an urgent need for the inclusion of an accurate diagnostic workup of infertile men leading to the choice of the most adequate follow-up for each particular pathological condition. The follow-up of women who have become pregnant as a result of the ART attempt has also to be personalized. This should be done taking into account both the basic data extracted from the patient's file and those derived from the experience gathered during the latest attempt. Last but not least, the individual condition of each couple has to be taken into account when counseling the patients as to the urgency of the actions to be taken to resolve their fertility problem.

Diagnosis and management of idiopathic recurrent pregnancy loss (RPL): Current immune testing and immunomodulatory treatment practice in the United Kingdom

Recurrent pregnancy loss (RPL) affects 1.9 % of couples. Despite the severe physical, psychological, and economic impact of RPL, miscarriage care provision remains highly heterogeneous. Due to the absence of strong scientific evidence, national and international guidelines on the diagnosis and treatment of this condition remain unclear and often contradictory. In the absence of identifiable RPL-associated risk factors, when the condition is termed “idiopathic”, immunological tests and immunomodulatory treatments are sometimes suggested even though the contribution of aberrant immune activity to this condition remains undetermined. Through an online survey, distributed across the UK (37.7% response rate), a high variation in clinical practice was detected, with multiple RPL definitions utilized and different tests employed for potential risk factor identification. Immunological testing was found to be provided in 7.9 %(N = 3) of the included clinics. Moreover, multiple therapies, including immunomodulatory ones were utilized for the management of idiopathic RPL. These findings highlight a need for additional research on the implication of immune activity in this condition. The high variation between clinics regarding the tests employed for the diagnosis and management of idiopathic RPL also underlines the need for guidelines to direct clinical practice, taking into consideration both the patients’ needs but also the strength of the available scientific evidence.

Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

Revision surgery for periprosthetic elbow infection: eradication rate, complications, and functional outcomes-a systematic review.

The aim of this systematic review was to investigate the outcomes of revision surgery after periprosthetic elbow infection (PEI). Eighteen studies with 332 PEI that underwent revision surgery were included. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported. Staphylococcus aureus was the most common microorganism (40%). Pre-operatively, the mean white blood cell count was 8400 ± 4000 per microliter; the mean C-reactive protein level was 41.6 ± 66.9mg/dl, and the mean erythrocyte sedimentation rate was 45 ± 66.9mm/h. The Coonrad-Morrey total elbow prosthesis represented 41.2% of the infected implant, and it also represented the most common system used for the PEI revision surgery. Two-stage revision and debridement and implant retention (DAIR) were the most common procedures performed for PEI, and, on the whole, they represented 35.7 and 32.7%, respectively. The eradication rate was 76% with 2-stage, 71% with resection arthroplasty (RA), 66.7% with 1-stage, 57.7% with DAIR, and 40% with arthrodesis (EA). DAIR showed a significantly lower eradication rate than 2-stage (P = 0.003). The mean postoperative Mayo Elbow Performance Score was significantly higher in patients who underwent DAIR, and 2-stage compared with RA (P < 0.001 for all). Postoperative flexion-extension ROM was significantly higher in patients who underwent DAIR compared with 1-stage, 2-stage, and RA (P < 0.001 for all). Moreover, 1-stage and 2-stage showed a significantly greater postoperative flexion-extension ROM compared with RA (P < 0.001 for all). Reoperations occurred in 40% of patients after EA, 33.3% after 1-stage, 26.9% after DAIR and RA, and 24.1% after 2-stage. Conversion to amputation occurred in 2.2% of patients after RA and 1% after DAIR. Two-stage revision and DAIR are the most common procedures used to manage PEI; however, the former procedure showed a significantly higher eradication rate. Resection arthroplasty showed a high eradication rate, but postoperative lower clinical and functional outcomes limit the indications for this technique. One-stage procedure showed a limited role in the current practice of PEI treatment. Level IV.