Evidence-based Treatment Algorithm Research Articles

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.

CME: Plantar fasciitis

CME: Plantar fasciitis Abstract. Plantar fasciitis is a common pathology in general practice. There are diverse treatment options described in the literature, but no simple treatment algorithm for general practice has been published yet. In this article, we present an evidence-based and simple treatment algorithm for use in busy general practices. Important to note, adequate patient education is crucial since the patient himself has a great influence on the healing process. In most cases, conservative treatment is promising and remission can be achieved within weeks or a few months.

Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm.

Chylous ascites (CA) is an uncommon complication that occurs from traumatic disruption of lymphatic channels after retroperitoneal surgery. The purpose of this study was to generate an evidence-based management strategy for CA by reviewing the current literature and available treatment modalities. A MEDLINE® literature review was performed for "chylous ascites." Individual patient data were extracted from case series and reports to create an efficacy analysis. Treatment modality, drain output, time to escalation of care and time to resolution were recorded. The efficacy analysis was utilized to generate a data-driven treatment algorithm. The literature review yielded 1,953 articles, from which 146 studies contributed data for 523 patients. The efficacy analysis included 245 patients, 168 (69%) of whom were managed successfully with conservative management (CM), at a median time to resolution of 11 days. Forty-eight patients underwent lymphangiography±embolization after CM, with a success rate of 85%. Thirty-one (12%) patients underwent surgical exploration. When treating CA, the patients who underwent stepwise management with CM followed by lymphangiography if CM failed experienced a resolution rate of 96.7%. An evidence-based treatment algorithm was created to guide treatment selection and duration of therapy before escalating to additional forms of therapy. In this report, we describe the largest conglomeration of iatrogenic CA cases from a literature review (523 cases) and efficacy analysis (245 cases), and created the first evidence-based treatment algorithm for this condition. Treatment success is substantial when using a stepwise combination of CM followed by lymphangiography±embolization.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries.

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Characterizing primary care for patients with major depressive disorder using electronic health records of a US-based healthcare provider

BackgroundMajor depressive disorder (MDD) is predominantly managed in primary care. However, primary care providers (PCPs) may not consistently follow evidence-based treatment algorithms, leading to variable patient management that can impact outcomes. MethodsWe retrospectively analyzed adult patients with MDD seen at Geisinger, an integrated health system. Utilizing electronic health record (EHR) data, we classified patients as having MDD based on International Classification of Disease (ICD)-9/10 codes or a Patient Health Questionnaire (PHQ)-9 score ≥5. Outcomes assessed included time to first visit with a PCP or behavioral health specialist following diagnosis, antidepressant medication switching, persistence, healthcare resource utilization (HRU), and treatment costs. ResultsAmong the 38,321 patients with MDD managed in primary care in this study, significant delays between diagnosis with antidepressant prescribing and follow-up PCP visits were observed. There was also considerable variation in care following diagnosis. Overall, 34.9% of patients with an ICD-9/10 diagnosis of MDD and 41.3% with a PHQ-9 score ≥15 switched antidepressants. An ICD-9/10 diagnosis, but not moderately severe to severe depression, was associated with higher costs and HRU. More than 75% of patients with MDD discontinued antidepressant medication within 6 months. LimitationsThe study population was comparable with other real-world studies of MDD, but study limitations include its retrospective nature and reliance on the accuracy of EHRs. ConclusionsManagement of patients with MDD in a primary care setting is variable. Addressing these gaps will have important implications for ensuring optimal patient management, which may reduce HRU and treatment medication costs, and improve treatment persistence.

Treatment options for chronic rhinosinusitis with nasal polyps.

Background: The management of chronic rhinosinusitis with nasal polyps (CRSwNP) is evolving, with an emphasis on treating the underlying type 2 inflammation. Objective: The objective was to summarize the updated evidence-based medical and surgical treatment recommendations for CRSwNP, including the position of biologics in the treatment algorithm. Methods: This review compared and contrasted the therapeutic recommendations presented by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Results: The long-term use of intranasal corticosteroids and the short-term use of oral corticosteroids are strongly recommended, whereas corticosteroid-eluting implants are considered an option. Although the use of saline solution rinses is recommended, there is uncertainty as to whether irrigation is more effective than sprays. Oral aspirin (ASA) desensitization, followed by ASA ≥ 300 mg daily for patients with ASA-exacerbated respiratory disease may be considered. In general, the use of antifungal agents offers no benefit and potential harm. Although the use of oral antibiotics for an acute exacerbation is still debated, oral and topical antibiotics are discouraged for subacute or chronic use. Antileukotrienes are inferior to intranasal corticosteroids and are unlikely to provide added benefit when used concomitantly. It is unlikely that the benefit of oral antihistamines and decongestants outweigh the potential harm. Dupilumab is recommended for severe CRSwNP when consensus-determined criteria are met. Omalizumab may be an option with concomitant poorly controlled asthma. Mepolizumab and reslizumab may be used, particularly in patients with concomitant uncontrolled asthma. In allergic fungal rhinosinusitis, oral and topical antifungals, antileukotrienes, allergen immunotherapy, and omalizumab are therapeutic options. Although surgical intervention is recognized to be of benefit for CRSwNP, there are no evidence-based criteria to indicate when maximum medical treatment has failed. Conclusion: An evidence-based CRSwNP treatment algorithm for when to recommend surgery and/or initiate or discontinue biologics to maximize quality of life and cost-effectiveness is still lacking.

Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections.

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms.

Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach. All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up. The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001). Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of ICD-10 for Diagnosing Mental Disorders In Russia, According to National Statistics and a Survey of Psychiatrists' Experience.

In order to assess the specifics of practical use of the ICD-10 Diagnostic Guidelines by Russian psychiatrists, official national statistics on the prevalence of a number of mental disorders in Russia in 2019 were compared with the results of meta-analyses of international epidemiological studies of these disorders. In addition, a number of items in the online psychiatrists' survey, relating to the diagnosis of schizophrenia, were analysed; 807 Russian psychiatrists took part in the online survey. Analysis of national statistics showed that domestic clinicians diagnose some mental disorders significantly less often than might be expected, according to data obtained by international epidemiological studies. The number of cases of bipolar affective disorder registered in Russia is 90-150 times less than that for the prevalence of this disorder, according to meta-analyses of epidemiological studies; for depression, the result is 50-70 times; for anxiety disorders, the number is 25-50 times, and for autism, it is 30 times. Instead of the above disorders, diagnoses of organic non-psychotic mental disorders and schizophrenia might have been used unreasonably often. Between 2005 and 2019, diagnosis of childhood autism changed significantly (an increase of more than 100%), while the frequency of diagnosing other mental disorders remained unchanged. The results of the online survey also showed largely perfunctory use of the ICD-10 Diagnostic Guidelines, with a third of respondents reporting never checking the diagnostic schedules, and another third doing so from time to time. In addition, the low estimates given by survey participants regarding practical utility of the ICD-10 Diagnostic Guidelines, along with a large percentage of respondents who do not directly use diagnostic criteria in their work, indicate the need to improve the clinical usefulness of the diagnostic guidelines in the latest revision of the ICD, including convenience of use in practice. The results of analysis of the Russian national mental health service statistic indicate that at least some diagnostic categories are not used by Russian psychiatrists exactly as ICD-10 suggests. The revealed discrepancy between the principles of diagnostics observed by domestic clinicians and international criteria may interfere with the use of evidence-based treatment algorithms, negatively affecting the quality of psychiatric care. In light of the upcoming transition to ICD-11 and in order to unify approaches to the diagnosis of mental disorders in our country, it is necessary to update and improve educational programmes for psychiatrists.

THE USE OF ICD-10 FOR DIAGNOSING MENTAL DISORDERS IN RUSSIA, ACCORDING TO NATIONAL STATISTICS AND A SURVEY OF PSYCHIATRISTS' EXPERIENCE

Purpose and methods. In order to assess the specifics of practical use of the ICD-10 Diagnostic Guidelines by Russian psychiatrists, official national statistics on the prevalence of a number of mental disorders in Russia in 2019 were compared with the results of meta-analyses of international epidemiological studies of these disorders. In addition, a number of items in the online psychiatrists' survey, relating to the diagnosis of schizophrenia, were analysed; 807 Russian psychiatrists took part in the online survey. Results. Analysis of national statistics showed that domestic clinicians diagnose some mental disorders significantly less often than might be expected, according to data obtained by international epidemiological studies. The number of cases of bipolar affective disorder registered in Russia is 90–150 times less than that for the prevalence of this disorder, according to meta-analyses of epidemiological studies; for depression, the result is 50–70 times; for anxiety disorders, the number is 25–50 times, and for autism, it is 30 times. Instead of the above disorders, diagnoses of organic non-psychotic mental disorders and schizophrenia might have been used unreasonably often. Between 2005 and 2019, diagnosis of childhood autism changed significantly (an increase of more than 100%), while the frequency of diagnosing other mental disorders remained unchanged. The results of the online survey also showed largely perfunctory use of the ICD-10 Diagnostic Guidelines, with a third of respondents reporting never checking the diagnostic schedules, and another third doing so from time to time. In addition, the low estimates given by survey participants regarding practical utility of the ICD-10 Diagnostic Guidelines, along with a large percentage of respondents who do not directly use diagnostic criteria in their work, indicate the need to improve the clinical usefulness of the diagnostic guidelines in the latest revision of the ICD, including convenience of use in practice. Conclusion. The results of analysis of the Russian national mental health service statistic indicate that at least some diagnostic categories are not used by Russian psychiatrists exactly as ICD-10 suggests. The revealed discrepancy between the principles of diagnostics observed by domestic clinicians and international criteria may interfere with the use of evidence-based treatment algorithms, negatively affecting the quality of psychiatric care. In light of the upcoming transition to ICD-11 and in order to unify approaches to the diagnosis of mental disorders in our country, it is necessary to update and improve educational programmes for psychiatrists.

The 2020 NBA Orthobiologics Consensus Statement

This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.

Prosthetics after construction of the outer genitalia for transmen

Growing awareness of gender identity issues and arising prevalence of female-to-male transsexualism is increasing demand for surgical solutions that deliver both aesthetically and functionally satisfying outer genitalia for transmen. This article summarizes the available prosthetic options, describes different surgical approaches and reviews the outcome of prosthetics for transmen with afocus on penile prosthesis in phalloplasty. Current international standards of care, reviews and original publications are critically reviewed and correlated with our own experience with more than 400transmen at two interdisciplinary referral centres in Frankfurt, Germany and London, UK. Despite of awide range of different phalloplasty techniques and prosthetic types, the currently most used technique is implantation of athree-piece, inflatable penile prosthesis in aradial-free-flap phalloplasty. There is still an ongoing debate about the number of implanted penile prosthesis cylinders, the use of customised corporoplasty-windsocks for the cylinder(s), and the location for the placement of the reservoir. At present there is only one penile prosthesis design for use in phalloplasties and long-term results are still pending. There is still no ideal implant available for the use in phalloplasties. The current literature does not provide evidence-based treatment algorithms, which is also due to alack of prospective randomised studies and validated measurement tools for the postoperative outcome. Initial data for the first transmen-specific penile prosthesis as well as an increase of transgender studies might lead to an improvement of treatment and the quality-of-life of the affected transmen.

The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model.

Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is a novel device that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis. Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis. Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively. Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.

The evolving treatment landscape of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a severe disease with poor prognosis and shortened life expectancy. Treatment has traditionally involved the sequential use of endothelin receptor agonists, prostacyclin therapies, and nitric oxide pathway modulators, which each have distinct mechanisms of action leading to pulmonary vasodilation, and improvement in exercise capacity, hemodynamic measures, and clinical outcomes for patients with PAH. This article provides a review of goals of therapy in PAH, determinants of prognosis and levels of patient risk, and additional factors that guide treatment decision making. Recent research in combination therapies has created a paradigm shift in the treatment of PAH and will be reviewed. Additionally, recent updates to the American College of Chest Physicians guidelines will be reviewed along with the updated evidence-based treatment algorithm. Finally, trial data will be evaluated for the recently developed agent selexipag and improved treprostinil delivery formulations that may provide enhanced convenience.

Systemic long-term impact of clinical pathways: UPMC experience with hysterectomy patients

Clinical pathways are defined as evidence-based, multidisciplinary care algorithms that outline essential steps in the management of patients. Pathway implementation in healthcare and industries outside of healthcare demonstrated success in reduction of inefficiencies and elimination of waste of financial and other resources by standardizing processes. The UPMC Health System introduced an evidence-based pathway treatment algorithm for hysterectomy in 2012 with an overarching goal of reducing variations in surgical care and abdominal hysterectomy rates, thereby promoting cost containment and decreased patient morbidity. In 2016, we reported on the impact of hysterectomy pathways on the reduction of open hysterectomy rates and improved patient outcomes between 2012 and 2014. In this follow-up commentary, we looked at years 2015 to 2019 to evaluate the continued success of hysterectomy pathway initiative. Initial studies, as well as follow-up results, both led to the understanding that hysterectomy clinical pathways serve as an effective instrument in decreasing the rates of open hysterectomies, thus reducing complications and undesired practice variability while providing consistent care. We concluded that physician and patient factors that impact the utilization of hysterectomy pathways must be continuously monitored to ensure optimal quality of care for hysterectomy patients. Introduction of clinical pathways across health systems represent an opportunity to introduce a systematic and sustainable change with the goal of achieving improved health outcomes locally and globally.

Integrated TB and HIV care for Mozambican children: temporal trends, site-level determinants of performance, and recommendations for improved TB preventive treatment

BackgroundPediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Implementation and operational barriers affect adherence to guidelines in many resource-constrained settings, negatively affecting patient outcomes. This study aimed to assess performance in the pediatric HIV and TB care cascades in Mozambique.MethodsA retrospective analysis of routine PEPFAR site-level HIV and TB data from 2012 to 2016 was performed. Patients 0–14 years of age were included. Descriptive statistics were used to report trends in TB and HIV indicators. Linear regression was done to assess associations of site-level variables with performance in the pediatric TB and HIV care cascades using 2016 data.ResultsRoutine HIV testing and cotrimoxazole initiation for co-infected children in the TB program were nearly optimal at 99% and 96% in 2016, respectively. Antiretroviral therapy (ART) initiation was lower at 87%, but steadily improved from 2012 to 2016. From the HIV program, TB screening at the last consultation rose steadily over the study period, reaching 82% in 2016. The percentage of newly enrolled children who received either TB treatment or isoniazid preventive treatment (IPT) also steadily improved in all provinces, but in 2016 was only at 42% nationally. Larger volume sites were significantly more likely to complete the pediatric HIV and TB care cascades in 2016 (p value range 0.05 to < 0.001).ConclusionsMozambique has made significant strides in improving the pediatric care cascades for children with TB and HIV, but there were missed opportunities for TB diagnosis and prevention, with IPT utilization being particularly problematic. Strengthened TB/HIV programming that continues to focus on pediatric ART scale-up while improving delivery of TB preventive therapy, either with IPT or newer rifapentine-based regimens for age-eligible children, is needed.

Do Antimicrobial Resistance Patterns Matter? An Algorithm for the Treatment of Patients With Impetigo

Background Impetigo, a highly contagious bacterial skin infection commonly occurring in young children, but adults may also be affected. The superficial skin infection is mainly caused by Staphylococcus aureus (S. aureus) and less frequently by Streptococcus pyogenes (S. pyogenes). Antimicrobial resistance has become a worldwide concern and needs to be addressed when selecting treatment for impetigo patients. An evidence-based impetigo treatment algorithm was developed to address the treatment of impetigo for pediatric and adult populations. Methods An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists employed a modified Delphi technique to develop the impetigo treatment algorithm. Treatment recommendations were evidence-based, taking into account antimicrobial stewardship and the increasing resistance to oral and topical antibiotics. Results The algorithm includes education and prevention of impetigo, diagnosis and classification, treatment measures, and follow-up and distinguishes between localized and widespread or epidemic outbreaks of impetigo. The panel adopted the definition of localized impetigo of fewer than ten lesions and smaller than 36 cm2 area affected in patients of two months and up with no compromised immune status. Resistance to oral and topical antibiotics prescribed for the treatment of impetigo such as mupirocin, retapamulin, fusidic acid, have been widely reported. Conclusions When prescribing antibiotics, it is essential to know the local trends in antibiotic resistance. Ozenoxacin cream 1% is highly effective against S. pyogenes and S. aureus, including methycyllin-susceptible and resistant strains (MRSA), and may be a suitable option for localized impetigo.J Drugs Dermatol. 2021;20(2):134-142. doi:10.36849/JDD.2021.5475 THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

Do Antimicrobial Resistance Patterns Matter? An Algorithm for the Treatment of Patients With Impetigo.

Impetigo, a highly contagious bacterial skin infection commonly occurring in young children, but adults may also be affected. The superficial skin infection is mainly caused by Staphylococcus aureus (S. aureus) and less frequently by Streptococcus pyogenes (S. pyogenes). Antimicrobial resistance has become a worldwide concern and needs to be addressed when selecting treatment for impetigo patients. An evidence-based impetigo treatment algorithm was developed to address the treatment of impetigo for pediatric and adult populations. An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists employed a modified Delphi technique to develop the impetigo treatment algorithm. Treatment recommendations were evidence-based, taking into account antimicrobial stewardship and the increasing resistance to oral and topical antibiotics. The algorithm includes education and prevention of impetigo, diagnosis and classification, treatment measures, and follow-up and distinguishes between localized and widespread or epidemic outbreaks of impetigo. The panel adopted the definition of localized impetigo of fewer than ten lesions and smaller than 36 cm2 area affected in patients of two months and up with no compromised immune status. Resistance to oral and topical antibiotics prescribed for the treatment of impetigo such as mupirocin, retapamulin, fusidic acid, have been widely reported. When prescribing antibiotics, it is essential to know the local trends in antibiotic resistance. Ozenoxacin cream 1% is highly effective against S. pyogenes and S. aureus, including methycyllin-susceptible and resistant strains (MRSA), and may be a suitable option for localized impetigo.J Drugs Dermatol. 2021;20(2):134-142. doi:10.36849/JDD.5475 THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

V.I.T.A.M. in COVID 19: A Systematic Approach to a Global Pandemic.

IntroductionIn the unprecedented era of COVID-19, ongoing research and evolution of evidence has led to ever-changing guidelines for clinical monitoring and therapeutic options. Formulating treatment protocols requires the understanding and application of the evolving research.ObjectiveThe primary objective of this study is to present a systematic evidence-based approach to synthesize the necessary data in order to optimize the management of COVID-19.MethodsAt Mayo Clinic Florida, we developed a multidisciplinary centralized COVID Treatment Review Panel (TRP) of expert pulmonologists, intensivists, infectious disease specialists, anesthesiologists, hematologists, rheumatologists, and hospitalists that in real-time reviews the latest evidence in peer-reviewed journals, the available clinical trials, and help guide the rapid application of therapeutics or interventions to the patient and the bedside provider.Results/ConclusionsThe multi-disciplinary team approach of synthesizing clinical data and coordinating care is effective in responding to rapidly evolving and changing evidence. Systematic data collection and evidence-based treatment algorithms enable physicians to rapidly translate the current literature to clinical practice, and improve care and outcomes of patients.

Implementation of a treatment algorithm to decrease incidence of paralysis post endovascular thoracoabdominal aorta repair

Spinal cord ischemia (SCI) is a rare but devastating complication following aortic repair. Despite improvements in operative management and critical care of aortic disease patients, SCI remains one of the most serious and common complications after these procedures. Early recognition and rescue interventions can augment the outcome and reduce the morbidity or avoid permanent dysfunction. This is a single institution experience of creating an evidence-based algorithm for the treatment of SCI in patients after thoracoabdominal endovascular aortic repair (TEVAR). We implemented an evidence-based treatment algorithm for the management of acute SCI after TEVAR. A total of 131 TEVAR cases were reviewed, 59 cases preimplementation, and 72 cases postimplementation of an SCI treatment algorithm. Lower extremity motor and/or sensory deficits were identified in 5.1% of preimplementation and 4.2% of postimplementation cases. SCI treatment interventions included increasing the mean arterial pressure (MAP) (66% pre and 100% post), placing lumbar drain (33% pre and 33% post), performing carotid subclavian bypass (33% pre and 33% post), initiating naloxone drip (66% pre and 100% post), and administering glipizide (0% pre and 100% post, P<.05). Long-term paralysis occurred in 66% of preimplementation and 0% of postimplementation cases. By creating and implementing an SCI treatment algorithm we reduced both, time to detection and time to effective treatment of SCI and significantly improved our patients' neurological outcomes.