Evidence-based Algorithm Research Articles

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.

Management of Articular Cartilage Defects in the Knee: An Evidence-Based Algorithm

Focal articular cartilage lesions of the knee are a challenging disease entity due to the poor regenerative properties of hyaline cartilage that often lead to degenerative joint disease. Surgery is indicated to alleviate symptoms, restore function, and return to desired activities when conservative treatment fails. Providers must consider defect size and severity, compliance with the postoperative rehabilitation protocol including weight-bearing restrictions, and patient expectations in their clinical decision-making. Smaller defects may be treated with arthroscopic chondroplasty, bone marrow stimulation, and osteochondral autologous transfer. Alternative surgical options for larger defects include osteochondral restoration using fresh vs. cryopreserved allografts, autologous chondrocyte implantation, and particulated juvenile allograft cartilage. This article will review available treatment options and provide an evidence-based treatment algorithm to guide the orthopaedic clinician's clinical decision-making.

Abstract 2554: Development/validation of a molecular and clinical evidence-based algorithm for selecting optimal precision therapeutic strategy for cancer patients - continuous study

Abstract Background: The integration of genotyping and genomics in clinical practice has brought about significant advancements in precision oncology. However, a persistent challenge for treating oncologists lies in selecting the most effective patient-specific therapeutic strategy due to the molecular rationale, disease relevance, and patient-specific issues. To address this challenge, we have developed an algorithm that incorporates both molecular and clinical evidence-based criteria to rank therapeutic strategies in order to deliver optimal care and improve outcomes in patients with malignancy. The purpose of this part of our studies was to evaluate the effectiveness and accuracy of our novel algorithm. Methods: History of present illness and comprehensive genomic profiling results of 306 patients with malignant tumors were reviewed by Avera Molecular Tumor Board (MTB) from June 2021 to February 2023. Therapeutic recommendations were provided with the Matching Score that we used in the I-PREDICT study based on molecular matching only as well as with the Ranking Score calculated by our novel algorithm with the criteria not only focusing on molecular matching, but also including disease relevance, patient-specific clinical considerations and treatment availability as weighting factors (Cohort 2). The other 50 patients with previously treated solid tumors reviewed by MTB (before 2018) and treatment recommendations provided with Matching Score only, were used as a control group (Cohort 1). The matching rates from recommendations and treatment outcomes of the patients were then assessed. Results: In Cohort 1, of the 50 patients, 33 patients (66%) received matched therapeutic plans recommended by our MTB. The other 17 patients were not on a matched plan from the MTB. At 12 weeks, 12 patients (36.4% of 33 patients) remained progression free, including 8 patients (24.2%) who were progression free at 6 months. The other 21 patients (63.6% of 33 patients) could not be assessed due to treatment termination per drug toxicity or death before the follow-up time point. The median PFS/overall survival (OS) for patients with a Matching Score > 50% (N = 17) were 7.5/10.5 months, whereas with Matching Score ≤ 50% (N = 16) were 3/7.35 months. In Cohort2, of the 306 patients, 130 (42.5 %) patients have initiated matched therapeutic plans and follow-up is ongoing. Updated results will be presented at the meeting. Conclusion: Our novel molecular and clinical evidence-based algorithm may be used to support oncologists’ decision-making to utilize the most clinically appropriate and effective therapeutic options to benefit patients. Further validation studies and development of a user-friendly computational ranking platform based on the algorithm are planned in order. Citation Format: Yuliang Sun, Tobias Meissner, Rachel Elsey, Crystal Hattum, Casey Williams. Development/validation of a molecular and clinical evidence-based algorithm for selecting optimal precision therapeutic strategy for cancer patients - continuous study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2554.

Successful demand management in diagnostic immunology testing

AimsWe investigated whether we could have a material and sustained impact on immunology test ordering by primary care clinicians by building evidence-based and explanatory algorithms into test ordering software.MethodsA service...

Evidence-based educational algorithm “Anki” for optimization of medical education

Anki is an open-sourced educational platform that utilizes a spaced repetition-based algorithm for information retention. This application has become increasingly popular among medical students and residents over recent years. The aim of this review was to describe this novel education technique, provide reasons for its adoption, and summarize the available literature regarding the efficacy of this method. With the recent COVID-19 pandemic, the medical education paradigm has undergone dynamic shifts. With self-learning independent of lectures on the rise prior to the pandemic, COVID-19 served as a catalyst to increase Anki popularity. The all-encompassing, free of charge, and open-sourced structure of Anki was an ideal fit during times of isolated study. This review will allow current residents and medical students to recognize advantages of this evidence-proven study techniques to increase learning efficacy. A systemic review of papers across all medical journals available on PubMed was conducted to identify studies published without time constraints. The search was for (Anki) and (spaced repetition residency). Available outcome data was summarized and discussed for residents and medical students independently. We found that Anki use has steadily increased among both medical students and residents. The application was regarded highly by users when surveyed. Many studies showed a statistically significant increase in exam performance associated with Anki use and high levels of satisfaction among residents and medical students. As burnout and time constrictions threaten educational workflow, Anki may serve as a powerful tool to improve the quality of learning. Further data needs to be collected and analyzed in residency specialties where Anki use may already exist but be underreported. Additionally, research is warranted to provide more high-quality evidence of Anki’s efficacy among medical students. Further research can be used to promote adoption of this technique among medical students and pre-meds early in their careers.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools.

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Incomplete Fractures of Distal Long Bones Among Children in Early Stages of Mobility: Few Concerns for Physical Child Abuse at a Single Pediatric Level I Trauma Center.

This study aimed to describe the characteristics, reported mechanism of injury, fracture morphology, and level of physical abuse concern among children in the early stages of mobility diagnosed with an incomplete distal extremity long bone fracture. A retrospective chart review was performed for all children aged 10 to 12 months with an incomplete fracture of a distal forearm or distal lower limb who were reportedly pulling up, cruising, or ambulating, and who were evaluated by the child abuse pediatrics team at a single pediatric level I trauma center. Of the 29 patients who met inclusion criteria, the child abuse pediatrics team had concerns about physical child abuse for 3 children. Not every case with an unknown or discrepant history of injury was deemed concerning for abuse, but all 3 for whom the team determined that concern was warranted had an unknown or discrepant history. All 3 of these children had distal forearm fractures; 1 child had multiple concomitant fractures (including a scapular fracture), and 2 had evidence of bone healing at initial presentation. Each of these observations raises concern for abusive injury based on current evidence. Both-bone buckle fractures of the radius/ulna and tibia/fibula were the most common type of incomplete distal fracture. This age group presents a unique challenge when designing evidence-based algorithms for the detection of occult injuries in emergency departments. Incomplete fractures of a distal limb are commonly related to a fall and may be considered "low specificity" for physical abuse. However, some publications conclude they should prompt universal physical abuse screening. Our small study indicated that the presence or absence of certain risk factors may provide additional information which could help guide the need for a more thorough evaluation for occult injury in early-mobile children with incomplete distal extremity long bone fractures. Ongoing research is warranted.

Five-Year Outcomes of the SuperB Trial: A Multicenter Randomized Controlled Trial Comparing Heparin-Bonded Endograft to Surgical Femoropopliteal Bypass.

This study aims to compare the 5-year outcomes of endoluminal bypass (EB) using heparin-bonded self-expanding covered stents versus bypass surgery for extensive femoropopliteal disease, including technical and clinical outcomes and health status. The surgical femoropopliteal bypass was the gold standard to treat peripheral arterial disease (PAD) for decades; however, endovascular treatment modalities are now recommended for most femoropopliteal lesions. One-year data of a randomized controlled trial comparing EB with surgical bypass (SB) have shown a faster recovery, less morbidity, and comparable patency rates between the two techniques. To date, long-term randomized controlled data regarding both techniques are lacking. Five-year results of a multicenter randomized controlled trial comparing EB with SB in patients with femoropopliteal artery disease were evaluated based on intention-to-treat and per-protocol analyses. At 5-year follow-up, primary, primary-assisted, and secondary patency rates were 36.2%, 52.4%, and 68.1% for EB and 49.4%, 72.2%, and 77.8% for SB, respectively (p=0.608). Freedom from target lesion revascularization (fTLR) was 34.1% for EB and 57.6% for SB (p=0.365). In both groups, the ankle-brachial index, Rutherford classification, and walking distance significantly improved compared with baseline without differences between groups at follow-up. Freedom from major amputation rate was 92.6% in the EB group and 96.2% in the SB group (p=0.361). The 36-Item Short-Form Health Survey showed no significant differences between groups. Treatment of extensive femoropopliteal disease with self-expanding covered stents provides comparable clinical-related and health-related questionnaire outcomes when compared with SB through 5 years of follow-up. However, the EB is related to a higher number of reinterventions. This present study is the first to report five-year outcomes comparing an endoluminal (EB) using heparin-bonded self-expanding covered stents with surgical bypass (SB) for long and complex femoropopliteal disease. Although the advantages of treatment with EB are mostly seen in the early period after treatment, the outcomes support the use of EB for this indication and seems to be a valid and safe alternative for bypass surgery. Future trials comparing various endovascular strategies may provide further guidance for the development of an evidence-based treatment algorithm.

Current Approaches for Monitoring of Patients with Inflammatory Bowel Diseases: A Narrative Review.

Patients with inflammatory bowel diseases (IBD) require proactive monitoring both during the active phase to evaluate therapeutic response and during the remission phase to evaluate relapse or colorectal cancer surveillance. However, monitoring may vary between patients with ulcerative colitis (UC) and Crohn's disease (CD), with distinct tools and intervals. This narrative review aims to focus on modern approaches to IBD monitoring, considering international guidelines and expert consensus. The most recent European diagnostic guidelines advocate a combination of clinical, laboratory, endoscopic, and radiological parameters to evaluate the disease course of patients with IBD. Unfortunately, the conventional symptom-based therapeutic approach does not improve long-term outcomes and there is no single ideal biomarker available. Endoscopy plays a key role in evaluating response to therapy as well as monitoring disease activity. Recently, bedside intestinal ultrasound (IUS) has gained increasing interest and diffusion as it appears to offer several advantages including the monitoring of therapeutic response. In light of growing clinical advances, we present a schematic evidence-based monitoring algorithm that can be easily applied in clinical practice which combines all major monitoring modalities, including noninvasive tools such as IUS and video-capsule endoscopy.

Development of an evidence-based diagnostic algorithm for infection in patients with transcutaneous osseointegration following amputation.

Introduction: Transcutaneous osseointegration following amputation (TOFA) confers better mobility and quality of life for most patients versus socket prosthesis rehabilitation. Peri-TOFA infection remains the most frequent complication and lacks an evidence-based diagnostic algorithm. This study's objective was to investigate preoperative factors associated with positive intraoperative cultures among patients suspected of having peri-TOFA infection in order to create an evidence-based diagnostic algorithm. Methods: We conducted a retrospective study of 83 surgeries (70 patients) performed to manage suspected lower-extremity peri-TOFA infection at a specialty orthopedic practice and tertiary referral hospital in a major urban center. The diagnosis of infection was defined as positive intraoperative cultures. Preoperative patient history (fevers, subjective pain, increased drainage), physician examination findings (local cellulitis, purulent discharge, implant looseness), and laboratory data (white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and external swab culture) were evaluated for association with subsequent positive intraoperative cultures using regression and area under receiver-operator curve (AUC) modeling. Results: Peri-implant limb pain (highly correlated with infection), ESR (highly correlated against infection), positive preoperative swab (moderately correlated with infection), gross implant motion (moderately correlated against infection), and erythema or cellulitis of the transcutaneous region (mildly correlated with infection) were variables included in the best AUC model, which achieved an 85 % positive predictive value. Other clinical findings and laboratory values (notably CRP and WBC) were non-predictive of infection. Conclusions: This seminal investigation to develop a preoperative diagnostic algorithm for peri-TOFA infection suggests that the clinical examination remains paramount. Further evaluation of a wider spectrum of clinical, laboratory, and imaging data, consistently and routinely collected with prospective data techniques in larger cohorts of patients, is necessary to create a robust predictive algorithm.

Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application.

High blood pressure affects approximately 116 million adults in the United States. It is the leading risk factor for death and disability across the world. Unfortunately, over the past decade, hypertension control rates have decreased across the United States. Prediction models and clinical studies have shown that reducing clinician inertia alone is sufficient to reach the target of ≥80% blood pressure control. Digital health tools containing evidence-based algorithms that are able to reduce clinician inertia are a good fit for turning the tide in blood pressure control, but careful consideration should be taken in the design process to integrate digital health interventions into the clinical workflow. We describe the development of a provider-facing hypertension management platform. We enumerate key steps of the development process, including needs finding, clinical workflow analysis, treatment algorithm creation, platform design and electronic health record integration. We interviewed and surveyed 5 Stanford clinicians from primary care, cardiology, and their clinical care team members (including nurses, advanced practice providers, medical assistants) to identify needs and break down the steps of clinician workflow analysis. The application design and development stage were aided by a team of approximately 15 specialists in the fields of primary care, hypertension, bioinformatics, and software development. Digital monitoring holds immense potential for revolutionizing chronic disease management. Our team developed a hypertension management platform at an academic medical center to address some of the top barriers to adoption and achieving clinical outcomes. The frameworks and processes described in this article may be used for the development of a diverse range of digital health tools in the cardiovascular space.

The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline.

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for asurgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including aCochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for astructured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by atimely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

An Evidence-Based Algorithm of Management of Heatstroke in the Emergency Department.

Annual rates of heat illness and heat-related deaths have been increasing across the United States as more regions of the country have been experiencing heat waves of extreme ambient temperatures of prolonged durations. According to the Centers for Disease Control and Prevention, heat illnesses have become the leading cause of weather-related deaths. This article critiques and describes the findings of a systematic review by C. Rublee et al. (2021). The review was conducted to develop an evidence-based algorithm specific for management of heatstroke in the emergency department with implications for improving recognition, initiating rapid cooling, and providing supportive care to reduce patient mortality and morbidity.

Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm.

Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.

Selection of Cloud Vendors for Medical Centers Using Personalized Ranking With Evidence-Based Fuzzy Decision-Making Algorithm

Selection of Cloud Vendors for Medical Centers Using Personalized Ranking With Evidence-Based Fuzzy Decision-Making Algorithm

Knee osteoarthritis: disease burden, available treatments, and emerging options.

Osteoarthritis (OA) is a prevalent condition that affects nearly 528 million people worldwide, including 23% of the global population aged ⩾40, and is characterized by progressive damage to articular cartilage, which often leads to substantial pain, stiffness, and reduced mobility for affected patients. Pain related to OA is a barrier to maintaining physical activity and a leading cause of disability, accounting for 2.4% of all years lived with disability globally, reducing the ability to work in 66% of US patients with OA and increasing absenteeism in 21% of US patients with OA. The joint most commonly involved in OA is the knee, which is affected in about 60%-85% of all OA cases. The aging population and longer life expectancy, coupled with earlier and younger diagnoses, translate into a growing cohort of symptomatic patients in need of alternatives to surgery. Despite the large number of patients with knee OA (OAK) worldwide, the high degree of variability in patient presentation can lead to challenges in diagnosis and treatment. Multiple society guidelines recommend therapies for OAK, but departures from guidelines by healthcare professionals in clinical settings reflect a discordance between evidence-based treatment algorithms and routine clinical practice. Furthermore, disease-modifying pharmacotherapies are limited, and treatment for OAK often focuses solely on symptom relief, rather than underlying causes. In this narrative review, we summarize the patient journey, analyze current disease burden and nonsurgical therapy recommendations for OAK, and highlight emerging and promising therapies-such as cryoneurolysis, long-acting corticosteroids, and gene therapies-for this debilitating condition.

A systematic review of studies on the diagnostics and classification system used in surgically treated, acute, isolated, unstable syndesmotic injury: a plea for uniform definition of syndesmotic injuries.

To this day, diagnostic standards and uniform definition for acute, isolated syndesmotic injuries are missing. The aim of the current study was to conduct a systematic review of the classification systems and diagnostics currently applied and to propose a best evidence diagnostic approach. Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials, and Embase were searched from inception to June 5, 2022, for studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. First, all classifications used in the eligible studies were identified and illustrated according to the individual syndesmotic structures injured. Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intra-operatively), was analyzed, including the applied cutoff criteria. Ten out of 4190 studies, comprising 317 acute ligamentous syndesmotic injuries, met the inclusion criteria. Seven studies facilitated one of the three different classification systems (Calder, West Point, or Sikka classification). Eight studies based their indication for surgery on a combination of clinical and radiographic examinations and two on radiographs only. The most applied clinical tests were the external rotation stress test and squeeze test. The most common radiologic diagnostics were plain radiographs and MRI. Intraoperatively, instability was verified most commonly using arthroscopy. Current classifications and diagnostics for syndesmotic injuries are heterogeneous, often cannot be attributed to the ligaments injured. An evidence-based diagnostic algorithm based on noninvasive diagnostics and an anatomy-based classification for acute syndesmotic instability is presented.

International Experience with Glomus Tumours: An Algorithm to Improve Diagnostic Accuracy

Background Glomus tumours are benign tumours which most frequently affect the upper extremities, often the subungual regions of the digits. The classic triad of presenting symptoms include cold hypersensitivity, point tenderness and paroxysmal pain. The absence of a visible lesion or a lack of a complete triad of symptoms, renders these lesions notoriously difficult to diagnose. The aim of this study is to analyse the referral pathways and misdiagnosis rates in relation to management of upper limb glomus tumours at our institution and compare this to the international experience. Methods We conducted a retrospective review of all glomus tumours treated at our institution over a twenty year period. Medical records, radiological imaging and histopathology reports were reviewed to identify patient, disease and treatment-related factors. A literature review of published case series of upper limb glomus tumours was performed to assess referral pathways, management and misdiagnosis rates. Results Twenty three upper limb glomus tumours were treated at our institution between 2000 and 2022. The mean age of diagnosis was 52.56 years (27-63 years) with a male preponderance 17/23 (74%). The overall rate of misdiagnosis was 70% based upon histological request forms at the time of surgery. The lowest rates of misdiagnosis were associated with management by hand surgery specialists. Eight published case series were identified in the literature with misdiagnosis a common phenomenon. Referral to hand surgeons appears to improves diagnostic accuracy. We present an evidence-based algorithm to recommend optimal management which may guide clinicians and improve patient outcomes.