Evidence-based Treatment Plan Research Articles

Rate of Whole-Breast Hypofractionated Radiation Therapy Before Versus After Virtual Tumor Board Implementation.

The virtual tumor board (VTB) is a multidisciplinary group of specialist physicians who remotely educate the treating physician on the development of an evidence-based cancer treatment plan that will enhance patient outcomes according to the available literature. The use of hypofractionated (HF) radiation therapy (RT) is a preferred approach according to National Comprehensive Cancer Network guidelines and is encouraged by the VTB, when appropriate. An observational, cohort study using prior authorization and claims data were conducted to show how the relative use of HF and conventional fractionated (CF) RT changed after the implementation of the VTB. Orders and claims for qualifying patients from 1 year before launch (August 2016) to 1 year after launch (August 2018) of the VTB were extracted. Claims were examined to observe which patients received CF (28-35 fractions) versus HF (15-21 fractions) RT. χ2 tests were used to assess the association between time period and the ordering and use of HF RT. Logistic regressions were used to test the association, after adjusting for the patient's age, urbanicity, local average income, and the RT modality used. After implementation, we observed a significantly higher percentage of orders for HF RT (60.3% [n = 1,254 of 2,079] v 53.2% [n = 1,010 of 1,899]; P < .001) and claims for HF RT (71.5% [n = 1,143 of 1,598] v 59.0% [n = 941 of 1,595]; P < .001). Relative to before implementation, the adjusted odds of an order for HF RT was 1.35 (CI, 1.19 to 1.54), and the adjusted odds of a claim for HF RT was 1.76 (CI, 1.52 to 2.04). After the VTB was implemented, there was a significant increase in HF RT orders and claims.

Deciding without data: clinical decision-making in pediatric orthopedic surgery.

Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic. We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study'). Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions. With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.

Abstract 5738: Gaps in biomarkers and health literacy among young-onset colorectal cancer patients, survivors and caregivers

Abstract The rise of young-onset colorectal cancer (YO-CRC) is an alarming public health issue. The proportion of new cases diagnosed in young people (20-49) had increased from 6% in 1990 to 11% in 2013 and coincided with the declining CRC cases in older people. YO-CRC patients face unique clinical challenges, as many are diagnosed at advanced stages of the disease and subjected to aggressive treatments. With the increase of targeted therapies and precision medicine available to them, patients.and their caregivers must understand the different treatment plans and options that could be suitable for them. So the decisions are best aligned with their unique tumor characteristics and the preferences of patients and their caregivers and articulated appropriately to providers. A cross-sectional study was conducted and patients and survivors (N=885) completed an online survey with 11 questions related to biomarkers and treatment options literacy. In addition, self-identified unrelated caregivers of YO-CRC patients (N=203) completed a similar survey. The average age of patients, survivors, and caregivers was 40-49. The majority of patients/survivors are college graduates (73%) and (40%) completed an advanced degree. Similarly, caregivers were mostly college graduates (79%) and (43%) had an advanced degree. Despite the fact that 73% of stage IV patients felt informed before treatment began, only 54% reported they received biomarker testing before treatment was initiated. However, out of these respondents (41%) stated their provider discussed biomarker testing at diagnosis and only half were informed about their results. The majority of respondents stated they were not made aware of biomarkers from their medical team and their patient biomarker education came from an internet search (56%), a family friend (22%) or patient navigator (22%). A majority were female (91%) were more likely to have biomarkers tested than males (9%) with 60% living in a suburban area, 20% urban area and in 18% in rural areas. While many caregivers report they serve as a liaison between patients and medical information retrieval, the majority of caregivers (55%) reported that they did not fully understand the critical aspects of patients' medical treatment plans and needs. Multiple studies have shown that patient-centered care improves patients' outcomes. Our organization promotes patient empowerment and encourages patients and their families to use medical information to develop an evidence-based treatment plan together with their physicians and care team to provide a roadmap for patients to navigate their journey. Our study identified numerous obstacles to achieving this goal. Further studies of physicians and other medical team members may shed light on reasons why the majority of patients and their caregivers reported a gap in information and understanding medical needs. Citation Format: Kimberly Newcomer, Tamara Springer, Never2Young Board, Danielle Peterson, Ronit Yarden. Gaps in biomarkers and health literacy among young-onset colorectal cancer patients, survivors and caregivers [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5738.

Challenges in remaining "UpToDate"

Our understanding of the prevalence of mental health disorders (MHDs) in society is in the midst of a paradigm shift: where MHDs were once considered rare within a population, studies through the last decade have converged to the conclusion that they are, in fact, near universal. Consequently, the demand for mental health treatment has resulted in the training of Primary-Care Physicians (PCPs) to identify, diagnose, and treat common MHDs. As generalists, PCPs require specialised point-of-care clinical resources to educate their patients and provide them with evidence-based treatment plans; UpToDate is one such resource. As a database of synthesized peer-reviewed medical information, written and approved by physician-experts from their review of contemporary peer-reviewed literature, this resource is considered a gold standard. Here, we examine an MHD-specific investigative case study on Generalized Anxiety Disorder where the synthesized UpToDate medical information was found to be in conflict with the original studies. In this era of unrelenting bombardment of digital data, the responsibility of assessing the truth of the information falls to the consumer. While a reliance on reputable information-sharing platforms facilitates both the access and assessment of truth, we discuss the risks of unintended errors, their propagation, and the potential impact at the point-of-care.

Evolution of Treatment for Anemia in Chronic Kidney Disease

Evolution of Treatment for Anemia in Chronic Kidney Disease

Impact of Pulmonary Embolism Response Team on Anticoagulation Prescribing Patterns in Patients With Acute Pulmonary Embolism

Introduction: Anticoagulation remains the mainstay pharmacotherapy for acute pulmonary embolism (PE), but multiple treatment options exist. The Pulmonary Embolism Response Team (PERT) is a multidisciplinary group that evaluates patients, formulates evidence-based treatment plans, and mobilizes resources. The objective of this study was to characterize the anticoagulation prescribing patterns made by PERT and to determine the clinical impact of anticoagulant selection. Materials and Methods: This was a retrospective analysis of patients evaluated by PERT from 2016 to 2018. Multivariable linear regression was conducted to determine predictors of length of stay (LOS). Results: A total of 209 patients were evaluated by PERT and received anticoagulation on discharge. Of those, 47% received a non-vitamin K oral anticoagulant (NOAC), 29% received warfarin, and 23% received low-molecular-weight heparin. Patient preferences and comorbidities were the most common reasons for NOAC omission. Patients who received NOACs had a shorter median LOS than warfarin (6.1 [4.6-7.6] days vs 10.9 [8.4-13.4] days; P < .05). Selection of NOAC upon discharge was the only factor independently associated with reduced LOS (β coefficient: −0.6; 95% CI: −1.01 to −0.18; P < .01). Conclusion: The most common recommendation made by PERT was to initiate a NOAC upon discharge, resulting in shorter hospital LOS compared to patients who received warfarin.

The Clinical Conundrum of Managing Ischemic Stroke in Patients with Immune Thrombocytopenia.

Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.

Identifying education, knowledge and communication gaps in biomarker testing between YO-CRC patients, caregivers, and their medical team.

e16115 Background: The proportion of new young-onset colorectal cancer (YO-CRC) cases diagnosed in young people (20-49) had doubled over the past 3 decades, and it is becoming an alarming public health issue. YO-CRC patients face unique clinical challenges, as many are diagnosed at advanced stages of the disease and subjected to aggressive treatments. With the increase of targeted therapies and precision medicine available, NCCN and ASCO guidelines recommend that all stage IV, metastatic CRC patients be tested for 4 biomarkers in addition to MSI-H. However, not all eligible patients benefit from biomarker testing and biomarker-driven therapies. Methods: We conducted an online survey to assess patients, survivors and caregivers’ knowledge and understanding of biomarker testing and whether they feel empowered to discuss with their doctor different treatment options based on their unique tumor characteristics and their preferences. Results: The cross-sectional study was completed by patients and survivors (N = 885) and unrelated caregivers of YO-CRC patients (N = 203). The median age of patients and survivors was 42, and the median age of caregivers was also 42. The majority of the participants were college graduates. Although 82% of stage IV, YO-CRC patients felt informed before treatment began, only 70% indicated their tumor was tested for biomarkers, and 54% of them received biomarker testing before treatment initiation. Only 33% of patients reported they became aware of biomarkers by their medical team while others indicated resources such as internet searches, family and friends, or patient navigators. Many of the caregivers who reported that they served as a liaison between patients and medical information retrieval felt that they did not fully understand the critical aspects of the patients' medical treatment plan. Conclusions: Multiple studies have shown that patient-centered care improves patients’ outcomes. Our organization encourages patients and their families to use medical information to navigate their journey. Our patient-reported study suggests that there are gaps in patients’ and caregiver’s understanding of biomarker testing that may hinder patient's empowerment for reaching evidence-based shared-decision treatment plan together with their physicians.

Vancomycin-resistant enterococci causing bacteriuria in hospitalized patients from Northwest India

Background: Vancomycin-resistant enterococci (VRE) are an important opportunistic pathogen in hospitalized patients due to their resistance to commonly administered antimicrobial agents. Material and Methods: A pilot study consisting of 100 urinary enterococcal isolates with significant bacteriuria (>105 CFU/ml) was conducted to assess the resistance pattern in our hospital. Culture, identification, and antibiotic sensitivity testing were performed as per standard protocols. Resistance to vancomycin was confirmed by minimum inhibitory concentration method using commercially available E strips (Hi Media). Results: Fifty-four percent (54/100) of isolates were Enterococcus faecalis, 33% (33/100) Enterococcus faecium followed by 13% (13/100) nonfaecalis nonfaecium species. 4% (4/100) of enterococci were vancomycin resistant out of which 1 (25%) was resistant to linezolid. All VRE were sensitive to nitrofurantoin. Conclusion: Emerging resistance to vancomycin in cases of significant bacteriuria found in our study raises a concern for reserving higher antibiotics such as linezolid, daptomycin, and quinupristin-dalfopristin. Efforts are required to assess the clinical significance of VRE in terms of colonization and infection and switch to evidence-based treatment plan.

Associations between neutering and idiopathic epilepsy in Labrador retrievers and Border collies under primary veterinary care in the UK

There are sparse published scientific data on associations between neutering and the severity and survival of dogs with idiopathic epilepsy. This study aimed to explore the timing of neutering with respect to onset of seizures in dogs with idiopathic epilepsy. Associations between neutering and both age of onset of seizures and the occurrence of cluster seizures or status epilepticus were examined. Survival analysis investigated the effects of sex-neuter categories. The median survival time of Border collies was compared with data previously reported in literature.The study included veterinary primary-care clinical data on 117 Labrador retrievers and 57 Border collies diagnosed with idiopathic epilepsy from the VetCompass project in the UK. The majority (74.2%; P≤0.001) of neutered cases were neutered before the onset of seizures. Age (years) at onset of seizures did not differ between dogs intact at time of onset and dogs neutered before onset of seizures (males 3.6 vs. 3.7; P=0.468 and females 3.4 vs. 4.1; P=0.154). Neuter status was not associated with the occurrence of cluster seizures (males P=0.947 and females P=0.844). Dogs intact at onset of seizures had longer median survival times than dogs neutered before onset of seizures (males, 1436 days vs. 1234 days; P=0.019; females, 1778.5 days vs. 1261 days; P=0.027). Median survival time of 1393 days for Border collies was longer than previously reported (P≤0.001). These results do not support recommendations to neuter dogs with idiopathic epilepsy within an evidence-based treatment plan.

The Chinese Association for the Study of Pain (CASP): Expert Consensus on the Cervicogenic Headache.

Cervicogenic headache is a relatively common but unique form of headache, and in China, as well as in several other countries, both diagnosis and a clear evidence-based treatment plan remain controversial. Therefore, the Chinese Association for the Study of Pain organized a meeting of pain management experts and created an expert consensus on the diagnosis and treatment of cervicogenic headache in China. This article summarizes the conclusions of the consensus group regarding the epidemiology, etiology, clinical features, diagnosis, differential diagnosis, treatment, and rehabilitation of cervicogenic headache in China.

QIM19-118: Oral Anti-Cancer Therapy Initiation: A Standardized Approach for Patient Care and Education

Background: The availability and popularity of oral anti-cancer therapy has recently increased. In this shift of delivery, control over downstream steps in the process moves to patients, families, and the extended care team. Unique challenges have been identified including effective patient education, adherence, and monitoring. The purpose of this quality improvement project was to standardize the approach to initiating oral anti-cancer patient care. Methods: A quality improvement team developed and implemented a standard approach for before, during, and after initiation of oral anti-cancer therapy. Key components included ensuring completion of informed consent, electronic orders within an evidence-based treatment plan, and adherence monitoring with a specific emphasis on patient education. Education prior to initiating therapy was standardized through both an education folder and one-on-one teaching sessions with an oncology nurse. A voluntary, anonymous 4-question paper survey (deemed clinical quality improvement by the IRB) solicited feedback from patients to assess both the educational materials and teaching session. Questions included perceived acceptability of the content and whether materials guided conversation, provoked questions, and complimented the teaching. An opportunity for comments was provided. Results: A 3-month collection period yielded overwhelmingly positive results. 100% of patients (n=18) felt the education materials provided were “just right” and provoked discussion with the care team. 94% of patients felt the educational materials and teaching session were complimentary. Conclusions: As oral anti-cancer therapy becomes more common, it is vital to form a collaborative partnership with the patient, family, and the extended care team to ensure overall success. Standardized educational content supports the transfer of expert knowledge to ensure adherence, management, and patient safety, ultimately improving patient outcomes. A standard approach that includes informed consent, orders within a treatment plan, adherence monitoring, and patient education prior to initiating oral anti-cancer therapy is one way to ensure quality, comprehensive patient care.

BIO19-022: Reducing Patient Waiting Times for Treatment Decision Making, Helps in Improving the Treatment Planning Process

Background: Availability of care is an important characteristic of effective primary healthcare systems. Imbalanced oncologist to patient ratios (∼1600: 1.8 M in India, ∼23,000: 15 M in USA), impedes access to expertise. On average it takes a week or more to get an online expert review from leading cancer hospitals in the United States and in India. Such delays have an important psychosocial impact on the patient and caregivers. Patients worldwide often race to start treatments at non-expert centers and may experience worse health outcomes from lack of expert tumor board review of their cases. This study aimed to examine the impact of Navya, a health services technology, on reducing the patient wait time in real-time treatment decision making. Methods: Navya generates personalized treatment plans that maps 98.8% within NCCN Resource Stratified Guidelines [SABCS 2017, NCCN 2018]. This is vetted on mobile by oncologists at tertiary centers like TMC NCG to provide expert opinion reports to patients. Since 2015, approximately 25,775 patients from 60 countries have reached out for an online opinion. On the ground, 78% of patients received evidence-based treatments recommended by Navya [ASCO 2017]. The Navya system releases preliminary system-generated opinions for patients whose treatment plans fit high confidence based on NCCN Guidelines and prior expert reviews. The mean reduction in time between a system-generated opinion and an expert-reviewed opinion was studied in a prospective cohort of patients between July 1, 2017, and August 30, 2018. Results: 313 patients received a system-generated treatment plan in the study period. Only approximately 10% of these plans were modified by experts to add additional treatment details since these were cases with high confidence in treatment decision-making. Navya delivered a preliminary treatment plan on an average of 86 hours (SD, 153 hours) prior to the expert response time. Of the 313 patients studied, 44% of patients would have waited an additional 3 days longer to receive an expert-reviewed recommendation. Conclusions: Navya’s NCCN and evidence-based treatment plans reduce the patient waiting times for an expert opinion average by 86 hours. This rapid confirmation of the right treatment plan at the time of patient need has potential to relieve patient anxieties at critical junctures in treatment decision-making and helps improve the treatment-planning process.

Abstract P3-16-01: Responding at patient's time of need: Scaling rapid access to evidence-based treatment plans

Abstract Background: Cancer patients worldwide feel intense anxiety, often racing to start treatments at non expert centers. Further, imbalanced oncologist to patient ratios (˜1600: 1.8 M in India, ˜23,000: 15M in USA), impedes access to expertise. We study the impact of rapid evidence based expert treatment plans in relieving patient anxiety. Navya, a health services technology, generates personalized treatment plans that maps within NCCN Resource Stratified Guidelines [SABCS 2017]. This is vetted on mobile by oncologists at tertiary centers like TMC NCG to provide expert opinion reports to patients. Since 2015, ˜19,457 patients from 57 countries have reached out for an online opinion. On the ground, 78% of patients received evidence based treatments recommended by Navya [ASCO 2017]. Methods: To assess impact of timeliness, a prospective series of patients (from Sep '17 to April '18) were asked: “Were you relieved to receive expert opinion report in [x] days?” “Does it matter to you to receive expert opinion report in 1 day?” To assess time savings, preliminary reports with treatment options from NCCN and TMC NCG guidelines were shared with patients who matched all guidelines criteria. Subsequently, expert opinion reports were shared as usual. Results: 543/701 patients responded to phone follow-up. 97% [± 3.2] were relieved to receive expert opinion reports in 1-2 days (103/106) vs 83% [± 3.8 ] for 3+ days (365/437). Of those not relieved by 3+ day turnaround, 83% stated that it would matter to receive expert opinion reports in 1 day (60/72). The first 300 preliminary reports shared in median time of 3.37 hours, resulted in 90% time savings vs expert opinion reports. On 10% of the preliminary reports, experts added information such as de-/escalating therapy (18/31), and additional diagnostic tests (6/31). Conclusions: Navya relieves patient anxieties by responding at the time of need with evidence based treatment plans. Scaling such health services technologies to patients worldwide is feasible. Citation Format: Ramarajan N, Srivastava R, Begum F, Gupta S, Pramesh C, Badwe R. Responding at patient's time of need: Scaling rapid access to evidence-based treatment plans [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-16-01.

Treatment and prognosis of immunoglobulin G4-related hepatobiliary disease

Currently, there is no randomized controlled clinical trial of immunoglobulin (Ig) G4-related diseases in the world. Therefore, the best-known evidence-based medical treatment plan for this disorder is unavailable. The goal of IgG4-related hepatobiliary diseases treatment is to alleviate symptoms, prevent disease-related complications and fibrosis progression. A definite diagnosis is warranted before treatment. Hormonal therapy has become the basis of induction of remission in IgG4-related hepatobiliary disease. An initial prednisone dose is 30 ~ 40mg/d or 0.6 mg.kg-1.d-1 for 2 to 4 weeks, thereafter, gradually the dose is reduced within 2-3 months. Maintenance therapy with low-dose glucocorticoids hormone (prednisone 2.5 to 5.0 mg/d) is recommended for 1 to 3 years to prevent disease recurrence. In addition, immunosuppressive agents are equally effective, and in most cases, hormone combined immunosuppressive therapy may respond. Rituximab, a monoclonal antibody is a promising drug for treatment of this kind of diseases.

Management of irreducible unilateral facet joint dislocations in subaxial cervical spine: two case reports and a review of the literature

BackgroundSkeletal and soft tissue damage are often associated with unilateral facet dislocations, which undoubtedly lead to instability of the spine and further increase difficulties in cervical reduction. This type of irreducible facet dislocation is usually accompanied with potential catastrophic consequences including neurological deficit and severe disability. Therefore, a consistent and evidence-based treatment plan is imperative.Case presentationThe literature regarding the management of traumatic unilateral locked cervical facet dislocations was reviewed. Two patient cases (a 30-year-old Asian man and a 25-year-old Asian woman) who suffered irreducible cervical facet dislocations were presented. These two patients received surgical treatments including posterior reduction by poking facet joints, adjacent spinous process fixation by wire rope banding, anterior plate fixation, and intervertebral fusion after the failure of skull traction and closed reduction. At the postoperative 24-month follow-up, intervertebral fusion was achieved and our patients’ neurological status improved based on the American Spinal Injury Association scale, compared with their preoperative status.ConclusionsUnilateral facet joint dislocations of subaxial cervical spine are difficult to reduce when complicated with posterior facet fractures or ligamentous injury. Magnetic resonance imaging can be beneficial for identifying ventral and dorsal compressive lesions, as well as ligamentous or capsule rupture. The combination of posterior reduction and anterior fixation with fusion has advantages in terms of clinical safety, ease of operation, and less iatrogenic damage.

Neuropsychology of Learning Disabilities: The Past and the Future.

Over the past 50 years, research on children and adults with learning disabilities has seen significant advances. Neuropsychological research historically focused on the administration of tests sensitive to brain dysfunction to identify putative neural mechanisms underlying learning disabilities that would serve as the basis for treatment. Led by research on classifying and identifying learning disabilities, four pivotal changes in research paradigms have produced a contemporary scientific, interdisciplinary, and international understanding of these disabilities. These changes are (1) the emergence of cognitive science, (2) the development of quantitative and molecular genetics, (3) the advent of noninvasive structural and functional neuroimaging, and (4) experimental trials of interventions focused on improving academic skills and addressing comorbid conditions. Implications for practice indicate a need to move neuropsychological assessment away from a primary focus on systematic, comprehensive assessment of cognitive skills toward more targeted performance-based assessments of academic achievement, comorbid conditions, and intervention response that lead directly to evidence-based treatment plans. Future research will continue to cross disciplinary boundaries to address questions regarding the interaction of neurobiological and contextual variables, the importance of individual differences in treatment response, and an expanded research base on (a) the most severe cases, (b) older people with LDs, and (c) domains of math problem solving, reading comprehension, and written expression. (JINS, 2017, 23, 930-940).

Charting the Course of Electroconvulsive Therapy: Where Have We Been and Where Are We Headed?

Electroconvulsive therapy (ECT) is one of the oldest and best treatments for severe mental illness. A safe and highly effective option for treatment-resistant mood disorders, ECT can be a lifesaving treatment for people suffering from catatonia and acute suicidality. Less recognized are the benefits of ECT in the treatment of primary psychotic disorders, Parkinson's disease, and status epilepticus. Evidence from multisite clinical trials in the past decade shows an evolving standard for the delivery of ECT to achieve and maintain remission and quality of life. Today, the optimal practice of ECT is defined by evidence-based treatment planning, including patient selection, choice of electrode placement and stimulus parameters, augmentation with pharmacotherapy, and the use of continuation/maintenance treatment. Research into biomarkers and neuroplasticity related to ECT response, as well as new investigational methods of delivering ECT, provide a glimpse into the future of this time-tested treatment. [Journal of Psychosocial Nursing and Mental Health Services, 54 (12), 39-43.].

Charting the Course of Electroconvulsive Therapy: Where Have We Been and Where Are We Headed?

Electroconvulsive therapy (ECT) is one of the oldest and best treatments for severe mental illness. A safe and highly effective option for treatment-resistant mood disorders, ECT can be a lifesaving treatment for people suffering from catatonia and acute suicidality. Less recognized are the benefits of ECT in the treatment of primary psychotic disorders, Parkinson's disease, and status epilepticus. Evidence from multisite clinical trials in the past decade shows an evolving standard for the delivery of ECT to achieve and maintain remission and quality of life. Today, the optimal practice of ECT is defined by evidence-based treatment planning, including patient selection, choice of electrode placement and stimulus parameters, augmentation with pharmacotherapy, and the use of continuation/maintenance treatment. Research into biomarkers and neuroplasticity related to ECT response, as well as new investigational methods of delivering ECT, provide a glimpse into the future of this time-tested treatment. [ Psychiatr Ann . 2016;46(11):647–651.]

Topical preparations and their use in dermatology.

The challenges of everyday clinical routine require dermatologists to have a basic knowledge of the composition of topical preparations as well as the regulatory background associated with their prescription. Proper selection, prescription, and application of topical preparations, depending on the respective indication, are key to professional and responsible medical practice. Problems commonly arise with respect to regulatory classifications (medicinal products, medical devices, or cosmetics), eligibility for reimbursement by the statutory health insurances (GKV), and insufficient declaration of vehicle systems. Apart from selecting the appropriate active substance and its proper concentration, choosing a suitable pharmaceutical (galenic) formulation - and thus utilizing the intrinsic effects thereof - is pivotal in enhancing the intended therapeutic effects. When prescribing individual formulations, dermatologists should, to the greatest extent possible, always resort to standardized extemporaneous preparations. Given the multitude of potential ingredients available for pharmaceutical formulations as well as the complexity resulting therefrom, arbitrary changes in quality or quantity of individual components are associated with a high risk of instability, thus jeopardizing safety and the rationale behind any given formulation. Optimal use of topical preparations also requires basic knowledge in pharmacokinetics as well as evidence-based treatment planning.