Evidence-based Treatment Algorithm Research Articles

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.

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.

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.

Real World, Single-Centre Experience of Pregnancy in Patients with Philadelphia Negative Myeloproliferative Neoplasms

Pregnancy in myeloproliferative neoplasms (MPN) is commonly associated with maternal and foetal complications due to increased risks of thromboembolic and haemorrhagic events and placental dysfunction. The incidence of UK pregnancies in MPN is estimated as 3·2/100 000 maternities per year (Alimam, S., et al 2016, Br J Haematol 2016; 175:31-36; Robinson et al, Br J Haematol 2020;189:625-34). Here we present pregnancy outcomes of MPN patients attending University College London Hospital (UCLH), a large UK tertiary referral centre, between 2015 and 2023. Twenty-three patients were identified with a median age at MPN diagnosis of 33 years (range (r), 13 - 46). The majority of patients (21/23, 91.3%) had a diagnosis of ET or triple negative (TN) thrombocytosis and 8.7% (2/23) a diagnosis of polycythaemia vera (PV). In 61.4% of pregnancies, diagnosis was known at conception. Regarding mutational status, JAK2V617F was present in 10/23 (43.5%) patients, CALR in 5/23 (21.7%) and MPL in 1/23 (4.3%). The remaining 7/23 (30.4%) patients were TN. Median VAF for JAK2V617F and CALR were 15.8% (r, 21.1 - 33%) and 25.9% (r, 5.7 - 46%), respectively. The cohort collectively experienced 57 pregnancies, 38 of which were managed at UCLH. Focusing on pregnancies managed at UCLH, median age at pregnancy was 34.5 years (r, 22 - 47). Conception was spontaneous in 31/38 (81.6%) pregnancies. Six (15.8%) patients required assisted conception and had a higher median age of 38.5 years (r, 35 - 47). Where gestation at delivery was known, 92.6% (25/31) of live births delivered at term (>37 weeks). Caesarean rate was significant at 41.9% (13/31), of which 61.5% were emergency sections. The live birth rate of the 57 overall pregnancies was 76.9% and 88.6% in the 38 managed at UCLH. At UCLH, we adopt an individualised approach to managing pregnant women with MPNs, working alongside obstetricians and obstetric haematology colleagues. Consequently, as shown in Table 1, there were bespoke regimens for individual patients. Low dose aspirin was prescribed throughout pregnancy in the majority (78.9%, 30/38) of pregnancies. In 18.4% (7/38), cytoreduction was established prior to pregnancy. In 42.9% (3/7), pegylated interferon (PegIFN) was commenced to optimise counts prior to pregnancy and in 42.9% (3/7) as long term count control. One patient was cytoreduced with hydroxycarbamide prior to pregnancy and subsequently switched to PegIFN. Low molecular weight heparin (LMWH) was administered at some point during pregnancy in 60.9% (14/23) of patients and 57.9% (22/38) of pregnancies. 65.8% (25/38) underwent monitoring with uterine artery (UA) dopplers. Median gestation for UA assessment was 20 weeks (r, 19 - 28). UA dopplers were reported as abnormal in 16% (4/25). In two patients, this was due to a raised combined pulsatility index, UA notching in one and was unspecified in one patient. Nine (39.1%) patients experienced foetal loss, with 12 miscarriages recorded across the total 57 pregnancies and 4 miscarriages in the 38 pregnancies managed at UCLH. Median maternal age was 31.5 (r, 24 - 42) and median gestation was 8 weeks (r, 5 - 24). Six (66.7%) patients experiencing foetal loss had a diagnosis of ET, 2 (22.2%) PV and 1 (11.1%) TN thrombocytosis. Three miscarriages occurred in one patient, who demonstrated a concurrent heterozygous prothrombin G20210A mutation in addition to ET. Eight (34.8%, 8/23) patients collectively experienced 11 haemorrhagic events. The majority (72.7%) were post-partum haemorrhage (PPH), 37.5% of which were classified as major or severe. Three (27.3%) bleeding events occurred whilst on aspirin monotherapy, 3 (27.3%) on combined LMWH and aspirin, 1 (9.1%) on LWMH alone and 1 (9.1%) on LMWH and PIFN. With regards to thrombosis, one patient with undiagnosed ET had a cerebral venous sinus thrombosis at 11-weeks gestation. A total of 2/23 (8.7%) patients' pregnancies resulted in hypertensive complications and pre-eclampsia, both resulting in delivery with caesarean section at 34 and 35 weeks. Although the live birth rate is encouraging, our data highlights that patients with MPN remain at increased risk of miscarriage, early delivery and haemorrhagic events. There remain inconsistencies in the management of pregnancy in MPN and, although we adopt an individualised patient-centred approach, there is an unmet need for further study and development of evidence based treatment algorithms.

Surgical considerations for glenoid bone loss in anterior glenohumeral instability: a narrative review.

Treatment algorithms may consider many factors like glenoid and humeral bone loss, or scores such as the instability severity index score (ISIS). As most studies only evaluate a part of these factors, there is still no evidence-based consensus estalished. Our study aims to summarize the surgical options for treatment of glenoid bone loss (GBL) in anterior shoulder instability. Based on the current available literature, surgical options including Bankart repair and glenoid bone augmentation should be considered while taking into consideration the degree of bone loss which has been divided into < 10%, 10-20% and > 20%. There are many new techniques evolving including arthroscopic anatomic glenoid reconstruction with bone blocks. Future long-term outcome studies and randomized controlled trials comparing established techniques will be needed for new evidence-based treatment algorithms.

A Systematic Review of Surgical Intervention versus Conservative Management in Treatment of Type II Odontoid Fracture in the Elderly

Background Odontoid fractures are the most common cervical spine fracture in elderly patients. It is clear that identifying an evidence-based treatment algorithm for odontoid fractures in these patients is paramount. Although patients of all ages with type I and III fractures are routinely treated in a cervical orthosis, the optimal treatment for type II geriatric odontoid fractures has been the topic of substantial debate in recent years. Aim of the Work To compare the outcome of conservative external immobilization versus surgical fusion in terms of morbidity, mortality, fusion rates and quality of life estimates in treatment of odontoid fracture type II in elderly. This will be done through a systematic review of literature addressing this research question. Patients and Methods In this Review, the authors are aiming at the analysis of the collective outcomes from studies comparing surgical and non-surgical management in elderly patients with odontoid fracture type II. Primary objective is to compare between the two groups in terms of mortality within the first year of injury and major and minor complications. Secondary objective is to evaluate the rate of fusion within a follow up period of 2-3 years. Results From the 17 included studies, six studies with total number of patients of 235 reported patients complicated with pneumonia with 9 (7.7%) patients in the non-surgically managed group and 12 (10.2%) patients, which was statistically insignificant with p-value 0.506 (NS). Only 2 studies reported patients with postoperative DVT with total number of patients of 109 from which 69 managed surgically and postoperative 3(4.3%) complicated with DVT which was statistically insignificant with P-value 0.182 (NS). Four studies with total number of 219 patients reported the patients complicated with Myocardial infarction, with 5 (4.9%) patients in the non-surgically managed group and 7 (6.0%) patients in the surgically managed group which was statistically insignificant with P-value 0.701 (NS), Three studies with total number of 177 patients reported the patients complicated with pressure ulcers in the non-surgically managed group 2 (2.1%) and wound infection in the surgically managed group 3 (3.7%) which is statistically insignificant with P value 0.517 (NS). Four studies with total number of patients of 175, reported minor complications such as blood transfusion, swallowing problems, UTI, in the non surgically managed group 10 (9.1%) and in the surgically managed group 16 (24.6%) which is statistically significant with P value 0.005 (HS). Conclusion Type II odontoid fractures in elderly patients are a common injury, and the mortality rate is substantial in patients treated with or without surgery. However, patients undergoing surgical treatment appear to have a decreased risk of mortality at least in the first year of trauma without an increase in the risk of significant complications, with higher rate of fusion.

Metastatic colorectal cancer-Modern treatment strategies and sequences

The treatment of metastatic colorectal cancer (mCRC) has been considerably expanded and relevantly improved in recent years with new strategies, such as resection of liver and/or lung metastases, induction and maintenance treatment, the establishment of targeted therapies and molecularly defined strategies in defined subgroups. This article presents evidence-based treatment options and algorithms, with afocus on systemic treatment.

BISCIT: Biliary interventions in critically ill patients with secondary sclerosing cholangitis—a study protocol for a multicenter, randomized, controlled parallel group trial

BackgroundProgress of cholangitis to cholangiosepsis is a frequent observation in patients with secondary sclerosing cholangitis in critically ill patients (SSC–CIP). Adequate biliary drainage may reduce episodes of cholangiosepsis and therefore stabilize liver function and improve survival. The primary objective of the BISCIT study is to demonstrate that scheduled biliary interventions will reduce incidence of cholangiosepsis, liver transplantation, or death in patients with SSC–CIP.MethodsA total of 104 patients will be randomized at ten study sites. Patients with SSC–CIP, confirmed by endoscopic retrograde cholangiography (ERC), will be randomized 1:1 either in the intervention group which will be treated with scheduled biliary interventions (i.e., therapeutic ERC) every 8 weeks for 6 months or in the control group which will receive standard of care. The randomization will be stratified by center. The composite primary efficacy endpoint is defined as (1) occurrence of death, (2) necessity of liver transplantation, or (3) occurrence of cholangiosepsis within 6 months following randomization.DiscussionProspective evaluation of endoscopic treatment procedures is urgently needed to establish an evidence-based therapeutic treatment algorithm in SSC–CIP. A positive trial result could change the current standard of care for patients with SSC–CIP. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications.Trial registrationThe trial was registered at ClinicalTrials.gov (NCT05396755, date of registration: May 31, 2022, last update: May 31, 2022).

I CAN HANDLE IRREPARABLE CUFF TEAR WITH REHABILITATION/I AM SURE THAT YOU CAN’T HANDLE ALL WITH REHAB

Rotator cuff tears (RCT) are one of the most commonly treated orthopaedic pathologies, yet controversy exists regarding the management of these injuries. Irreparable rotator cuff tears are unpredictable with respect to their clinical presentation. The spectrum of pain and functional disability varies widely. Rehabilitation protocol is always the first solution in treating irreparable cuff tears, but non-functional and painful shoulders (e.g., arthrosis) is an indication for surgery. Can we ask ourselves a question: where lies the limit of trying “persistent” surgical repair of massive irreparable RC lesions? There is a lack of high-quality comparative studies to guide treatment recommendations. Physical therapy compared to surgery is associated with a lower improvement in perceived functional outcome and higher clinical failure rate. However, there is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs. Treatment is based on patient factors and associated pathology and includes personal experience and data from case series. It has to be underlined that the winner is always team physiotherapist/surgeon, and their cooperation is crucial at all stages of therapy

Special Report: Bipolar Disorder II—Frequently Neglected, Misdiagnosed

Special Report: Bipolar Disorder II—Frequently Neglected, Misdiagnosed

Microvascular reconstructions in oral and maxillofacial surgery — Results of a survey among oral and maxillofacial surgeons in Germany, Austria, and Switzerland

This study aimed to evaluate the use of microvascular free flaps (MFF) in oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland.A dynamic online questionnaire, using 42–46 questions, was sent to OMF surgeons based in hospitals in Germany, Austria, and Switzerland. The questionnaire was evaluated internally and externally. Aside from general information, data were collected on organizational aspects, approaches, MFF types and frequency, presurgical planning, intraoperative procedures, perioperative medications, flap monitoring, and patient management.Participants mostly performed 30–40 MFF each year (11/53). Most stated that the COVID-19 pandemic did influence MFF frequency (25/53) to varying extents. Radial forearm flap was most frequently used (37/53), followed by ALT (5/53), and fibula flap (5/53). Primary reconstruction was performed by most participants (35/48). Irradiated bony transplants were mostly used for implant placement after 12 months (23/48). Most participants (38/48) used reconstruction plates, followed by miniplates (36/48), PSI reconstruction (31/48), and PSI miniplates (10/48). Regarding the postoperative use of anticoagulants, low-molecular-weight (37/48) and unfractioned heparins (15/48) were widely used, most often for 3–7 days (26/48). Clinical evaluation was mostly preferred for flap monitoring (47/48), usually every 2 h (34/48), for at least 48 h (19/48).Strong heterogeneity in MFF reconstructions in OMFS was found, especially regarding the timepoints of reconstruction, types of osteosynthesis, and postoperative MFF management. These findings provide the chance to further compare the different treatment algorithms regarding relevant MFF aspects, such as postoperative management. This could create evidence-based treatment algorithms that will further improve the clinical outcomes in MFF reconstructions.

Treatment of non-infectious retinal vasculitis.

Retinal vasculitis (RV) refers to an entity in which the retinal vasculature is inflamed, frequently with indications of inflammation elsewhere in the eye. Non-infectious RV can be idiopathic or associated with systemic disease, ocular conditions, and malignancy. It can also be classified based on the vessel affected: artery, vein, or both. Due to the lack of strong evidence-based treatment trials and algorithms for RV, physicians must often rely on their experience, which creates great variability in treating this entity. This article provides an overview of various treatment modalities used in the management of non-infectious RV, with a focus on immunomodulatory therapies. We outline a potential stepwise approach of starting with steroids to control the acute inflammation and subsequently changing to immunomodulatory therapy (IMT) for long-term treatment.

Surgical management of thoracolumbar junction fractures: An evidence-based algorithm

BackgroundThe management of thoracolumbar junction (TLJ) fractures, involving the restoring anatomical stability and biomechanics properties, still remains a challenge for neurosurgeons.Despite the high frequency of these injuries, specific treatment guidelines, set on biomechanical properties, have not yet been assumed. The present study is meant to propose an evidence-based treatment algorithm. The primary aim for the protocol validation was the assessment of postoperative neurological recovery. The secondary objectives concerned the evaluation of residual deformity and rate of hardware failure. Technical nuances of surgical approaches and drawbacks were further discussed. MethodsClinical and biomechanical data of patients harboring a single TLJ fracture, surgically managed between 2015 and 2020, were collected. Patients' cohorts were ranked into 4 groups according to Magerl's Type, McCormack Score, Vaccaro PLC point, Canal encroachment, and Farcy Sagittal Index. The outcome measures were the early/late Benzel-Larson Grade and postoperative kyphosis degree to estimate neurological status and residual deformity, respectively. Results32 patients were retrieved, 7, 9, 8, and 8 included within group 1, 2, 3, and 4, respectively. Overall neurological outcomes significantly improved for all patients at every follow-up stage (p ​< ​0.0001). Surgeries gained a complete restoration of post-traumatic kyphosis in the entire cohort (p ​< ​0.0001), except for group 4 which experienced a later worsening of residual deformity. ConclusionsThe choice of the most appropriate surgical approach for TLJ fractures is dictated by morphological and biomechanical characteristics of fracture and the grade of neurological involvement. The proposed surgical management protocol was reliable and effective, although further validations are needed.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability.

Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice. A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice. All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss. Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

Retrospective Analysis of a Clinical Algorithm for Managing Childhood Myopia Progression.

As the myopia epidemic unfolds, there is growing urgency to identify and implement effective interventions to slow myopia progression. This investigation evaluated the effectiveness of an evidence-based myopia treatment algorithm in a clinical setting among 342 consecutive children. This study aimed to evaluate effectiveness of a clinical treatment algorithm for myopia progression in children. A retrospective cohort analysis was performed using data from myopic children treated for at least 1 year with a defined treatment algorithm incorporating orthokeratology, multifocal lenses, and atropine. The main outcome measures were the percentage of children experiencing ≤0.25 D of myopic cycloplegic spherical equivalent autorefraction (CSER) progression and ≤0.10 mm of axial elongation at 1, 2, and 3 years. The secondary outcome measures were the cumulative absolute reduction of axial elongation values derived from age- and ethnicity-matched virtual control data at 1, 2, and 3 years. Mean annual CSER change values (excluding orthokeratology) were -0.30, -0.20, and -0.13 D at 1, 2, and 3 years, respectively, with 59, 56, and 60% of patients demonstrating ≤0.25 D of change over the prior year. Mean annual axial elongation values were 0.13, 0.12, and 0.09 mm at 1, 2, and 3 years, respectively, with 52, 46, and 65% of patients demonstrating ≤0.10 mm of change over the prior year. The cumulative absolute reduction of axial elongation values were 0.11, 0.20, and 0.29 mm for 1, 2, and 3 years, respectively. The treatment algorithm demonstrated effective control of CSER and axial length in a diverse group of progressive myopic children, supporting its use for the clinical management of childhood myopia.

Nutrition issues in the general medical ward patient: From general screening to specific diagnosis and individualized treatment.

Disease-related malnutrition in patients in the general medical ward remains a complex syndrome, which contributes to high morbidity and mortality, and seriously interferes with recovery from acute illness. Recently, there have been important advances in the development of consensus diagnostic criteria for malnutrition, and through the recent completion of large-scale trials, the understanding of pathophysiological pathways and evidence-based treatment algorithms to provide nutrition care to patients at risk for malnutrition in the hospital setting has advanced. There is need to identify more specific clinical parameters and blood biomarkers, which allow a more personalized approach to the malnourished patients, because not all patients show the same response to nutrition interventions. Recent studies have suggested that some nutrition biomarkers of inflammation, kidney function and muscle health, among others, predict treatment response to nutrition interventions and may help to personalize treatments. In addition to advancing the science, there is need for more education of students and treating teams in the hospital to improve the screening of patients at hospital admission regarding nutrition risk with the start of individualized nutrition support interventions, thereby bringing optimal nutrition care to the bedside.

Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options

Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tension-free, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

Management of treatment-related sequelae following colorectal cancer.

Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment. A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included. Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units. Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Super-refractory status epilepticus in adults

IntroductionSuper-refractory status epilepticus (SRSE) represents the culmination of refractory status epilepticus (RSE) and carries a significant risk of poor neurological outcome and high mortality. RSE is not defined primarily by seizure duration, but by failure to respond to appropriate antiseizure treatment. SRSE is present when a RSE persists or recurs after more than 24 h of treatment with anesthetics. No evidence-based treatment algorithms can be provided for SRSE. Therefore, we propose a pragmatic standard operating procedure (SOP) for the management of SRSE that addresses the existing uncertainties in the treatment of SRSE and provides options for resolution and decision-making.CommentsFirst, we recommend the assessment of persistent seizure activity and the evaluation of differential diagnoses to confirm correct diagnosis. Relevant differential diagnoses include psychogenic non-epileptic seizures, hypoxic, metabolic, or toxic encephalopathies, and tetanus. During SE or in severe encephalopathies, a so-called electroclinical ictal-interictal continuum may occur, which denotes an intermediate stage that cannot be defined with certainty as ictal or interictal by EEG and should not lead to harmful overtreatment. Because both prognosis and specific treatment options depend crucially on the etiology of SRSE, the etiological evaluation should be performed rapidly. When SRSE is confirmed, various pharmacological and non-pharmacological treatment options are available.ConclusionWe provide a pragmatical SOP for adult people with SRSE.

Assess and address: Screening and management of depression in patients with chronic heart failure.

About one in three patients with heart failure (HF) have depression. Comorbid HF and depression are associated with poor outcomes and increased health care burden. Clinical guidelines recommend routine depression screening in patients with HF. Depression screening was not being systematically implemented in an outpatient cardiology clinic. To create a sustainable process for a cardiology clinic to screen adults with chronic HF for depression, identify patients who have an elevated depression screening score and initiate an evidence-based treatment algorithm for patients with depressive symptoms. A nurse practitioner (NP)-led process improvement project administered the Patient Health Questionnaire (PHQ-9) tool to patients with HF. The score was reviewed by the NP and, if elevated, addressed with assessment and plan. Compliance was measured by the percentage of patients screened. Clinical impact was measured by percentage of patients with an elevated score with a documented treatment plan. Postimplementation results for four Plan-Do-Study-Act cycles were 38%, 68%, 72%, and 66%, respectively, with a total 63% of patients screened during the entire project. Twenty unique patients (13.2%) had elevated PHQ-9 scores; all had a documented treatment plan. We demonstrated how a screening protocol and an accompanying treatment algorithm can be successfully implemented in an outpatient cardiology clinic. Elements of success included a standardized screening protocol, a clinical support algorithm for treatment/referral, an optimized electronic medical record, and a follow-up system for patients with significant depressive symptoms. Stakeholder engagement throughout the project informed iterative changes and provided direction for sustainability.