Evidence-based Algorithm Research Articles

Associations Between Testing and Treatment Pathways in a Case of Pediatric Nonlesional Epilepsy: A Census Survey of NAEC Center Directors.

Epilepsy surgery is vital in managing of children with drug-resistant epilepsy. Noninvasive and invasive testing modalities allow for evaluation and treatment of children with drug-resistant epilepsy. Evidence-based algorithms for this process do not exist. This study examines expert response to a vignette of pediatric nonlesional epilepsy to assess associations in evaluation and treatment choices. We analyzed annual report data and an epilepsy practice survey reported in 2020 from 135 pediatric epilepsy center directors in the United States. Characteristics of centers along with noninvasive and invasive testing and surgical treatment strategies were collected. Multivariable logistic regression modeling was performed. The response rate was 100% with 135 responses included in the analyses. Most used noninvasive testing modalities included Neuropsychology evaluation (90%), interictal brain fluorodeoxyglucose-positron emission tomography (85%), and functional magnetic resonance imaging (MRI) (72%) with nearly half obtaining genetic testing. Choosing functional MRI was associated with stereo electroencephalography (EEG) (P = .025) and selecting Wada with subdural grid/strips (P = .038). Directors from pediatric-only centers were more likely to choose stereo EEG as opposed to combined centers (P = .042). Laser interstitial thermal therapy was almost 7 times as likely to be chosen as a treatment modality compared with open resection in dedicated pediatric centers (OR 6.96, P = .002). In a vignette of nonlesional childhood drug-resistant epilepsy, epilepsy center directors' patterns of noninvasive testing, invasive testing, and treatment were examined. Management choices were associated with pediatric versus combined pediatric/adult center characteristics. Expert opinions demonstrated equipoise in evaluation and management of children with drug-resistant epilepsy and the need for evidence-based management strategies.

Implementation of an algorithm for testing, diagnosis, and antibiotic stewardship of asymptomatic bacteriuria in pregnancy

BackgroundAsymptomatic bacteriuria (ASB) affects 2-15% of pregnant women, with 20-40% developing symptoms later. Symptomatic urinary tract infections (UTIs) are more common in pregnancy, with a prevalence of 33%, posing risks like preterm delivery, low birth weight, and maternal pyelonephritis. The gold standard for UTI detection is a urine culture, but point-of-care urinalysis dipsticks are frequently performed as screens during regular obstetric visits. Leukocyte esterase has been used to justify treatment in the asymptomatic, even with low sensitivity and specificity. Confirmatory tests are crucial to avoid false positives and ensure optimal outcomes. Current guidelines for urinalysis dipstick interpretation and the decision to treat ASB in pregnancy are limited. It remains unclear if an evidence-based algorithm can improve test utilization, diagnosis, and treatment decisions for ASB in pregnancy. ObjectivesThe primary objective of our study is to develop, implement, and evaluate an evidence-based algorithm to guide urinalysis interpretation, culturing, diagnosis, and antibiotic stewardship of asymptomatic bacteriuria in pregnant patients during routine obstetric visits. Study DesignThe project involves both retrospective and quasi-experimental prospective chart reviews of pregnant patients aged 18 and older, beyond 20 weeks gestation, from routine obstetric visits with urinalysis dipstick tests. A doctorate in clinical laboratory sciences student developed an educational algorithm to guide urinalysis dipstick interpretation, culturing necessity, and treatment decisions based on evidence-based practice. Our study considered patient records from February 1 – 28, 2022 as retrospective (pre-algorithm implementation) data and January 24 - February 22, 2023, as prospective (post-algorithm implementation) data. Data collected from the electronic medical record included de-identified patient information, urinalysis results, culture dates and outcomes, antibiotic prescriptions, UTI or ASB diagnoses, provider details, adverse pregnancy outcomes, and demographics. Data analysis using SPSS version 29 involved chi-square tests, likelihood ratios, and effect size calculations, with P-values <0.05 considered statistically significant. ResultsIn our study, we examined a total of 1,176 patient records. Pre-implementation data included 440 records, with 224 abnormal and 216 normal urinalyses. Post-implementation data encompassed 736 records, of which 255 were abnormal and 481 were normal. The patient demographics predominantly featured White (87%), with a median maternal age of 27 years and a gestational age of 32 weeks. Our pre-implementation analyses revealed significant associations between algorithm deviations with both culture utilization (P <.001) and antibiotic stewardship (P <.001). However, no significant associations were observed between algorithm deviations and adverse patient outcomes. Culture underutilization decreased significantly from 43.0% (189/440) pre-implementation to 29.5% (217/736) post-implementation (P < .001). The overall reduction in ASB prevalence from 16.3% (8/49) to 6.7% (10/67) suggests a decrease of nearly 60%. Additionally, antibiotic overprescription decreased significantly from 1.6% (4/258) pre-implementation to 0.8% (4/522) post-implementation (P = .003), with a reduction from 7.1% (3/42) to 2.4% (1/41) among abnormal urinalyses. ConclusionOur findings show a strong alignment between the use of the algorithm and subsequent clinical decisions, underscoring its potential to enhance patient care and management in obstetric settings. Notably, adherence to the algorithm was higher among providers displaying prudent antibiotic use.

Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department.

Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently. Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable. Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.

Beyond the distance between juridic and scientific decision-making process: An evidence-based prediction algorithm for professional liability assessment in healthcare-associated infections

BackgroundHAIs (Healthcare-Acquired-Infections) have been recently the subject of judgment n. 6386 pronounced on 3rd March 2023 by the Italian Supreme Court. This sentence provided three criteria to determine whether a health facility is responsible for the patient contracting a nosocomial infection, i.e. time criterion, topographical criterion and clinical criterion. Accordingly, the healthcare facility is obliged to prove the fulfillment of a series of preventive hygiene measures specifically detailed by the legislator. Herein, the positive predictive value of these criteria (“juridic criteria”) in the identification of professional liability for nosocomial infections was evaluated in comparison with clinical criteria reviewed by Infectious Disease specialists (“Infectious-Disease criteria”, i.e. presence of a Multidrug Resistant Organism (MDRO); development of surgical site infection; inadequate antibiotic therapy; inadequate disinfection). MethodsTwo retrospective cohorts were compared from the Portal of Telematic Services of the Ministry of Justice; 51 patients were extrapolated from Italian judgments concerning claims for Gram-negative nosocomial infections in the three-year period 2020–2022. On the other side, from the electronic database of University Hospital of Bari we extracted 349 patients affected by Gram-negative infections in the same timespan. Both “juridic” criteria and “Infectious-Disease” criteria were then applied to the full cohort after stratification for cohort of origin and after stratification for nosocomial or non-nosocomial infections. Predictive value of criteria was evaluated through receiver operating characteristic (ROC) curves and area under the curve (AUC). ResultsOverall, the incidence of definite nosocomial infections (according to final judgement or clinical records discharge letter) was 84 % in juridic cohort and 46 % in “real-world” series.Data suggested that the presence of all three juridic criteria [ROC AUC = 0.944 (95%CI = 0.924–0.963)] or the four clinical criteria [ROC AUC = 0.948 (95%CI = 0.928–0.969)] predicted well a case of nosocomial infection with professional liability.Moreover, by summarizing both criteria in a single classification system, the generated ROC curve (was the one with the highest AUC [0.9488 (95%CI = 0.928–0.969)].Accordingly, further tests were performed, evaluating the predictive value of one juridic criterium plus at one of more Infectious-Disease criteria. Interestingly, the ROCs curves demonstrated that the presence of at least 1 juridic criteria plus at least 2 Infectious Disease criteria reached a predictive value comparable to 2 or 3 juridic criteria. ConclusionsThe results highlight the efficiency of new criteria laid down in the judgment of the Italian Supreme Court to attribute liability for nosocomial infection despite the disputed distance between juridic and scientific decision-making process. In addition, the use of a combined score combining “juridic” and “Infectious-Disease” criteria provides a high-quality tool to be used by technical consultants to make up for lack of clinical documentation by passing judgments concerning litigation about professional liability in case of nosocomial infections. This sheds light on the possibility to face worldwide judicial inquiries with scientific rigor.

A classification algorithm for prioritizing surgery in Pediatric patients with idiopathic scoliosis when Long Surgical delays are expected.

To identify the clinical phenotypes associated with the rate of progression while waiting for surgery and propose a classification scheme for identifying subgroups of patients to prioritize for surgery when long surgical delays are expected. We reviewed the clinical and radiographic data of a prospective cohort of patients scheduled for IS surgery from 2004 to 2020 with a minimum 1-year wait prior to surgery. Candidate predictors consisted of age, sex, Risser sign, menarchal status, angle of trunk rotation, scoliotic curve type, and main Cobb angle at baseline when scheduled for surgery. Univariate and Regression Tree analysis were performed to identify predictors associated with the annual curve progression rate in the main Cobb angle between baseline and surgery. There were 214 patients (178 females) aged 15 ± 2 years, with a Risser sign 3.4 ± 1.6 and a main Cobb angle 55°±10° at baseline. The average wait prior to surgery was 1.3 ± 0.4 years. Only the Risser sign, menarchal status and sex were significantly associated with the annual progression rate. We have identified 3 clinically and significantly different groups of patients presenting slow (3 ± 4°/yr if Risser sign 3 to 5), moderate (8 ± 4°/yr if female with Risser sign 0 to 2 and post-menarchal), and fast (15 ± 10°/yr if Risser sign 0 to 2 and premenarchal or male) progression rates. We present an evidence-based surgical prioritization algorithm for pediatric idiopathic scoliosis that can easily be implemented in clinical practice when long surgical delays are expected.

Clinical algorithms for the monitoring and management of spontaneous, uncomplicated labour and childbirth.

To develop evidence-based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. Pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications. Health facilities in low- and middle-income countries. We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed, and Google on terms related to spontaneous, uncomplicated labour and childbirth up to 01 June 2023. Three case scenarios were developed to cover assessments and management for spontaneous, uncomplicated first, second and third stage of labour. The algorithms provide pathways for definition, assessments, diagnosis, and links to other algorithms in this series for management of complications. We have developed three clinical algorithms to support evidence-based decision making during spontaneous, uncomplicated labour and vaginal birth. These algorithms may help guide health care staff to institute respectful care, appropriate interventions where needed, and potentially reduce the unnecessary use of interventions during labour and childbirth.

Severe Thoracic Trauma Indications and Contraindications for Non-operative and Operative Treatment Strategies

Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At <4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, >6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.

Decreasing Premedication for Blood Transfusions: A Quality Improvement Project.

Premedication administration to patients who are to receive blood transfusions continues despite evidence of a lack of benefit when given to prevent febrile nonhemolytic or mild allergic transfusion reactions. Reviews of ordering practices and staff surveys on an adult inpatient hematology-oncology unit in our multisite oncology medical center indicated a lack of standardization and overuse of premedication in blood transfusions and a lack of knowledge of when it was appropriate to use premedication. A literature search was performed, and the evidence led to a proposal for a quality improvement (QI) project focused on development of an evidence-based algorithm to guide clinicians in when to administer which premedication, development of clear documentation for premedication plans, integration of the documented premedication plans into electronic orders for blood products, and staff education. Interventions included a hospital-wide algorithm and an electronic order to be integrated with a premedication plan for each patient on the adult hematology-oncology unit. Seven months after implementation of the intervention, premedication use among patients decreased by 57.6%, and the transfusion reaction rate decreased from 1% to 0.8%. Staff knowledge as measured by responses to pre- and postintervention surveys on the appropriate use of premedication also improved. Evidence-based interventions can reduce the incidence of premedication use in patients receiving blood transfusions.

Living systematic review and meta-analysis of plasma-concentrations of antipsychotic drugs in carriers and non-carriers of variant CYP450 genotypes: Living systematic review protocol

Introduction Carriers of variant alleles of genes that encode liver CYP450 and UGT enzymes may experience abnormal plasma levels of antipsychotics and, consequently, worse efficacy or tolerability. Although pharmacogenomics is a rapidly developing field, current guidelines often rely on limited, underpowered evidence. We have previously demonstrated that meta-analysis is a viable strategy for overcoming this problem. Here, we propose a project that will expand our previous work and create a living systematic review and meta-analysis of drug plasma level differences between carriers and non-carriers of variant genotype-predicted phenotypes for every pharmacokinetic drug-gene interaction relevant to commonly used antipsychotic drugs. Protocol First, a baseline systematic review and meta-analysis will be conducted by searching for observational pharmacogenomics-pharmacokinetic studies. Data on dose-adjusted drug plasma levels will be extracted, and participants will be grouped based on their genotype for each drug-gene pair separately. Differences in plasma drug levels between different phenotypes will be compared using a random-effect ratio-of-means meta-analysis. The risk of bias will be assessed using ROBINS-I, and the certainty of evidence will be assessed using GRADE. Following the establishment of baseline results, the literature search will be re-run at least once every six months, and the baseline data will be updated and re-evaluated as new evidence is published. A freely available website will be designated to present up-to-date results and conclusions. Discussion This systematic review will provide evidence-based results that are continuously updated with evidence as it emerges in the rapidly developing field of pharmacogenomics. These results may help psychiatrists in their decision-making, as clinicians are becoming increasingly aware of the patients’ genetic data as testing becomes more widespread and cheaper. In addition, the results may serve as a scientific basis for the development of evidence-based pharmacogenomics algorithms for personalized dosing of antipsychotics to mitigate potentially harmful drug-gene interactions.

Reduced Blood Culture Use in High-Volume Lung Transplant MICU Following a Stewardship Program, Northern California, 2021–2023

Introduction: There is a need to optimize blood culture (BC) utilization among hospitalized adults. A previous study showed an evidence-based BC algorithm improved BC utilization in a medical intensive care unit (MICU) at a large academic center. Our aim is to evaluate the impact of an intervention based on this algorithm on blood culture utilization in the MICU at Stanford Health Care, a referral center known for its high volume of solid organ transplants. Methods: We conducted a before-after study evaluating the impact of a BC diagnostic stewardship program in the MICU at Stanford Health Care, a 20-bed unit with an average of 20% lung transplant patients per day. All patients ≥18 years of age admitted to the unit during the study period were included. We adopted a previously published evidence-based algorithm detailing syndromes with low and high risk for bacteremia, which was referenced during patient rounds. Additionally, education and feedback to providers about BC utilization and indication inappropriateness was performed during leadership meetings every other month. We performed an interrupted time series analysis using historical data 17 months before the implementation of the blood culture stewardship program on April 1, 2022 and 8 months after. We assessed changes on BC utilization adjusted to patient days and crude mortality rate during the same period as a balancing measure. Results: Before the implementation of the program, the median BC utilization was 216 per 1,000 patient days (range 150–250 per 1,000 patient days). Following the introduction of the program, there was a significant decrease in blood culture utilization by 5% (95% CI -10% to -1%, p=.02; Figure 1). Post-intervention, the blood culture stabilized, with no significant increase observed (0.09% increase, 95% CI -0.7% to 1%, p=.81). The mortality rate, prior to the implementation of the program, had shown a significant downward trend of 1.4% over time (95% CI -3% to -0.2%, p=.02). After the intervention, a nonsignificant decrease of 8% was observed (95% CI -44% to 27%, p=.62; Figure 2), followed by a nonsignificant upward trend of 6% (95% CI -1% to 13%, p=.10). Conclusion: We observed a significant reduction in BC utilization after implementing the BC diagnostic stewardship program in a MICU frequented by a high number of lung transplant patients.

Multidisciplinary Development and Implementation of a Trial of Void Algorithm to Standardize and Reduce Indwelling Urethral Catheter Use.

Prolonged indwelling catheter use is a known risk factor for catheter-associated UTIs (CAUTIs). We sought to reduce catheter use by creating and implementing a trial of void (TOV) algorithm to standardize indwelling Foley catheter removal in surgical patients. We partnered with the Departments of General Surgery and Nursing to develop an evidence-based TOV algorithm for a step-down unit at a large urban teaching hospital. Our cohort included patients treated with intra-abdominal, thoracic, vascular, urologic, and gynecologic surgeries. The primary outcome was mean cumulative indwelling urethral catheter patient-days. For example, if 2 patients had catheters for 3 and 7 days, respectively, then cumulative catheter days would be 10. We analyzed changes in catheter use 90 days before and after algorithm implementation. The mean number of hospitalized patient-days before and after algorithm introduction did not differ (32.2 vs 32.0, P = .60). After implementation, mean cumulative catheter patient-days decreased (14.8 vs 9.9, P < .01), as did mean daily number of patients with catheters on the unit (3.7 vs 3.1, P = .02). There was 1 CAUTI before and after algorithm implementation, the latter deemed associated with algorithm nonadherence. Catheter use in a surgical floor control group where the algorithm was not implemented did not differ for any outcome over the same time period (P > .05). A multidisciplinary approach to standardize catheter care with a TOV algorithm is feasible and effective in reducing catheter use. Further research is needed to determine its impact on CAUTI rate.

Aetiological profile of acute encephalitis syndrome in Assam, India, during a 4-year period from 2019 to 2022.

Acute encephalitis syndrome (AES) is a major public health concern in India as the aetiology remains unknown in the majority of cases with the current testing algorithm. We aimed to study the incidence of Japanese encephalitis (JE) and determine the aetiology of non-JE AES cases to develop an evidence-based testing algorithm. Cerebrospinal fluid (CSF) samples were tested for Japanese encephalitis virus by ELISA and polymerase chain reaction (PCR). Multiplex real-time PCR was done for Dengue, Chikungunya, West Nile, Zika, Enterovirus, Epstein Barr Virus, Herpes Simplex Virus, Adenovirus, Cytomegalovirus, Herpesvirus 6, Parechovirus, Parvovirus B19, Varicella Zoster Virus, Scrub typhus, Rickettsia species, Leptospira, Salmonella species, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Plasmodium species and by ELISA for Mumps and Measles virus. Of the 3173 CSF samples, 461 (14.5%) were positive for JE. Of the 334 non-JE AES cases, 66.2% viz. Scrub typhus (25.7%), Mumps (19.5%), Measles (4.2%), Parvovirus B19 (3.9%) Plasmodium (2.7%), HSV 1 and 2 (2.4%), EBV and Streptococcus pneumoniae (2.1% each), Salmonella and HHV 6 (1.2% each) were predominant. Hence, an improved surveillance system and our suggested expanded testing algorithm can improve the diagnosis of potentially treatable infectious agents of AES in India.

Arrhythmogenic Cardiomyopathy: Current Updates and Future Challenges.

Arrhythmogenic cardiomyopathy (ACM) epitomises a genetic anomaly hallmarked by a relentless fibro-fatty transmogrification of cardiac myocytes. Initially typified as a right ventricular-centric disease, contemporary observations elucidate a frequent occurrence of biventricular and left-dominant presentations. The diagnostic labyrinth of ACM emerges from its clinical and imaging properties, often indistinguishable from other cardiomyopathies. Precision in diagnosis, however, is paramount and unlocks the potential for early therapeutic interventions and vital cascade screening for at-risk individuals. Adherence to the criteria established by the 2010 task force remains the cornerstone of ACM diagnosis, demanding a multifaceted assessment incorporating electrophysiological, imaging, genetic, and histological data. Reflecting the evolution of our understanding, these criteria have undergone several revisions to encapsulate the expanding spectrum of ACM phenotypes. This review seeks to crystallise the genetic foundation of ACM, delineate its clinical and radiographic manifestations, and offer an analytical perspective on the current diagnostic criteria. By synthesising these elements, we aim to furnish practitioners with a strategic, evidence-based algorithm to accurately diagnose ACM, thereby optimising patient management and mitigating the intricate challenges of this multifaceted disorder.

Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD

Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD

Selection of endoscopic resection technique for large colorectal lesion treatment.

Large nonpedunculated colorectal polyps ≥ 20 mm (LNPCPs) comprise 1% of all colorectal lesions. LNPCPs are more likely to contain advanced histology such as high-grade dysplasia and submucosal invasive cancer (SMIC). Endoscopic resection is the first-line approach for management of these lesions. Endoscopic resection options include endoscopic mucosal resection (EMR), cold-snare EMR (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). This review aimed to critically evaluate current endoscopic resection techniques. Evidence-based selective resection algorithms should inform the most appropriate endoscopic resection technique. Most LNPCPs are removed by conventional EMR but there has been a trend toward C-EMR for endoscopic resection of LNPCPs. More high-quality trials are required to better define the limitations of C-EMR. Advances in our understanding of ESD technique, has clarified its role within the colorectum. More recently, the development of a full thickness resection device (FTRD) has allowed the curative endoscopic resection of select lesions. Endoscopic resection should be regarded as the principle approach for all LNPCPs. Underpinned by high-quality research, endoscopic resection has become more nuanced, leading to improved patient outcomes.

A Practical Approach to Diagnosing and Managing Chronic Spontaneous Urticaria.

Chronic spontaneous urticaria (CSU) is an unpredictable inflammatory skin condition characterized by the spontaneous onset of itchy wheals, angioedema, or both, which occurs for longer than 6weeks overall. Despite the relatively straightforward diagnostic algorithm for CSU, relying primarily on a detailed medical history and only limited laboratory tests, patients often wait years to be diagnosed, with many cycling through different healthcare practitioners before a diagnosis is made. Even then, current treatment options for CSU are limited, with approximately half of patients resistant to standard-of-care second-generation antihistamines at standard or higher doses. As such, there is an unmet need for improved, streamlined management for patients with CSU. Here, we review the evidence-based diagnostic algorithm for CSU, consider the required steps of the diagnostic workup, and provide practical, real-world advice on the management of CSU to improve the timely diagnosis and care of patients with this debilitating disease.

Living systematic review and meta-analysis of plasma-concentrations of antipsychotic drugs in carriers and non-carriers of variant CYP450 genotypes: Living systematic review protocol.

Carriers of variant alleles of genes that encode liver CYP450 and UGT enzymes may experience abnormal plasma levels of antipsychotics and, consequently, worse efficacy or tolerability. Although pharmacogenomics is a rapidly developing field, current guidelines often rely on limited, underpowered evidence. We have previously demonstrated that meta-analysis is a viable strategy for overcoming this problem. Here, we propose a project that will expand our previous work and create a living systematic review and meta-analysis of drug plasma level differences between carriers and non-carriers of variant genotype-predicted phenotypes for every pharmacokinetic drug-gene interaction relevant to commonly used antipsychotic drugs. First, a baseline systematic review and meta-analysis will be conducted by searching for observational pharmacogenomics-pharmacokinetic studies. Data on dose-adjusted drug plasma levels will be extracted, and participants will be grouped based on their genotype for each drug-gene pair separately. Differences in plasma drug levels between different phenotypes will be compared using a random-effect ratio-of-means meta-analysis. The risk of bias will be assessed using ROBINS-I, and the certainty of evidence will be assessed using GRADE. Following the establishment of baseline results, the literature search will be re-run at least once every six months, and the baseline data will be updated and re-evaluated as new evidence is published. A freely available website will be designated to present up-to-date results and conclusions. This systematic review will provide evidence-based results that are continuously updated with evidence as it emerges in the rapidly developing field of pharmacogenomics. These results may help psychiatrists in their decision-making, as clinicians are becoming increasingly aware of the patients' genetic data as testing becomes more widespread and cheaper. In addition, the results may serve as a scientific basis for the development of evidence-based pharmacogenomics algorithms for personalized dosing of antipsychotics to mitigate potentially harmful drug-gene interactions.

Optimal Treatment Order With Fibula-Free Flap Reconstruction, Oncologic Treatment, and Dental Implants: A Systematic Review and Meta-Analysis.

Head and neck cancer (HNC) patients benefit from craniofacial reconstruction, but no clear guidance exists for rehabilitation timing. This meta-analysis aims to clarify the impact of oncologic treatment order on implant survival. An algorithm to guide placement sequence is also proposed in this paper. PubMed, Embase, and Web of Science were searched for studies on HNC patients with ablative and fibula-free flap (FFF) reconstruction surgeries and radiotherapy (RTX). Primary outcomes included treatment sequence, implant survival rates, and RTX dose. Of 661 studies, 20 studies (617 implants, 199 patients) were included. Pooled survival rates for implants receiving >60Gy RTX were significantly lower than implants receiving < 60Gy (82.8% versus 90.1%, P =0.035). Placement >1 year after RTX completion improved implant survival rates (96.8% versus 82.5%, P =0.001). Implants receiving pre-placement RTX had increased survival with RTX postablation versus before (91.2% versus 74.8%, P <0.001). One hundred seventy-seven implants were placed only in FFF with higher survival than implants placed in FFF or native bone (90.4% versus 83.5%, P =0.035). Radiotherapy is detrimental to implant survival rates when administered too soon, in high doses, and before tumor resection. A novel evidence-based clinical decision-making algorithm was presented for utilization when determining the optimal treatment order for HNC patients. The overall survival of dental prostheses is acceptable, reaffirming their role as a key component in rehabilitating HNC patients. Considerations must be made regarding RTX dosage, timing, and implant location to optimize survival rates and patient outcomes for improved functionality, aesthetics, and comfort.

Rehabilitation Treatment Specification System: Content and Criterion Validity Across Evidence-Based Voice Therapies for Muscle Tension Dysphonia.

Systematically improving voice therapy outcomes is challenging as the clinician actions (i.e., active ingredients) responsible for improved patient functioning (i.e., targets) are relatively unknown. The theory-driven Rehabilitation Treatment Specification System (RTSS) and standard, voice-specific terminology based on the RTSS (RTSS-Voice) may help address this problem. This qualitative study evaluated if the RTSS and RTSS-Voice can describe four evidence-based voice therapies for muscle tension dysphonia without missing critical aspects (content validity) and identify commonalities and differences across them (criterion validity). Qualitative interviews were completed between the clinicians (protocol experts) who developed and/or popularized the vocal function exercises, laryngeal reposturing, circumlaryngeal massage, and conversation training therapies as well as RTSS experts to produce RTSS specifications that met two consensus criteria: (a) The protocol expert agreed that the specification represented their treatment theory, and (b) the RTSS experts agreed that the specifications correctly adhered to both the RTSS framework and the RTSS-Voice's standard terminology. The RTSS and RTSS-Voice comprehensively described voice therapy variations across and within the four diverse treatment programs, needing only the addition of one new target: overall auditory-perceptual severity. The RTSS and RTSS-Voice exhibited strong content validity. The standard RTSS-Voice terminology helped identify, for the first time, commonalities and differences in treatment ingredients, targets, and mechanisms of action across four treatments developed for the same patient population. In the long term, the RTSS and RTSS-Voice could provide the framework for an ever-growing collection of clinically meaningful and evidence-based therapy algorithms with potential to improve research, education, and clinical care. https://doi.org/10.23641/asha.25537624.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies.

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.