Evidence-based Treatment Plan Research Articles

Guidelines for identification and treatment of individuals with attention deficit/hyperactivity disorder and associated fetal alcohol spectrum disorders based upon expert consensus.

BackgroundThe association of attention deficit/hyperactivity disorder (ADHD) and fetal alcohol spectrum disorders (FASD) results in a complex constellation of symptoms that complicates the successful diagnosis and treatment of the affected individual. Current literature lacks formal guidelines, randomized control trials, and evidence-based treatment plans for individuals with ADHD and associated FASD. Therefore, a meeting of professional experts was organized with the aim of producing a consensus on identification and treatment guidelines that will aid clinicians in caring for this unique patient population.MethodsExperts from multiple disciplines in the fields of ADHD and FASD convened in London, United Kingdom, for a meeting hosted by the United Kingdom ADHD Partnership (UKAP; www.UKADHD.com) in June 2015. The meeting provided the opportunity to address the complexities of ADHD and FASD from different perspectives and included presentations, discussions, and group work. The attendees worked towards producing a consensus for a unified approach to ADHD and associated FASD.ResultsThe authors successfully came to consensus and produced recommended guidelines with specific regards to identification and assessment, interventions and treatments, and multiagency liaisons and care management, highlighting that a lifespan approach to treatment needs to be adopted by all involved. Included in the guidelines are: 1) unique ‘red flags’, which when identified in the ADHD population can lead to an accurate associated FASD diagnosis, 2) a treatment decision tree, and 3) recommendations for multiagency care management.ConclusionsWhile clinically useful guidelines were achieved, more research is still needed to contribute to the knowledge base about the diagnosis, treatment, and management of those with ADHD and associated FASD.

International application of an online clinical informatics expert system for breast cancer.

e18037Background: Cancer patients have limited access to experts and evidence based treatment plans. Navya is a patented, clinical informatics system that uses clinical data as input to exhaustivel...

Psychiatric Comorbidity and Complications.

This article highlights the prevalence of co-occurring disorders among adolescents and underscores the complexity and opportunities of treating these patients in a systematic, comprehensive approach. As evidenced by this review, the need exists to develop and test models of care that integrate co-occurring disorders into both psychiatric and substance abuse treatment settings. The challenge for pediatric practitioners is to provide detailed assessments linked to evidence-based treatment plans to account for the variations in adolescent development and the unique risk factor profile of each patient. The issues related to co-morbidity are vast and continue to grow with rapidly increasing research literature.

The Effect of the Mulligan Knee Taping Technique on Patellofemoral Pain and Lower Limb Biomechanics

Background: Patellofemoral pain (PFP) affects 25% of the general population, occurring 2 times more often in females compared with males. Taping is a valuable component of the management plan for altering lower limb biomechanics and providing pain relief; however, the effects of alternative taping techniques, such as Mulligan knee taping, appear yet to be researched. Purpose: To determine whether the Mulligan knee taping technique altered levels of perceived knee pain and lower limb biomechanics during a single-legged squat (SLSq) in adult females with PFP. Study Design: Controlled laboratory study. Methods: A total of 20 female patients with PFP, aged 18 to 35 years, participated in this study. Participants performed 3 to 5 SLSq on their most symptomatic limb during a taped (Mulligan knee taping technique) and nontaped (control) condition. During the eccentric phase of the SLSq, the 3-dimensional kinematics (250 Hz) of the knee and hip and the ground-reaction forces (1000 Hz) and muscle activation patterns (1000 Hz) of the gluteus medius, vastus lateralis, and vastus medialis oblique were measured. Participants’ perceived maximum knee pain was also recorded after the completion of each squat. Results: Between-condition differences were found for hip kinematics and gluteus medius activation but not for kinetics or vastus medialis oblique and vastus lateralis muscle activity (timing and activation). Compared with the nontaped condition, the Mulligan knee taping technique significantly (P = .001) reduced perceived pain during the SLSq (mean ± SD: 2.29 ± 1.79 and 1.29 ± 1.28, respectively). In the taped condition compared with the control, the onset timing of the gluteus medius occurred significantly earlier (120.6 ± 113.0 and 156.6 ± 91.6 ms, respectively; P = .023) and peak hip internal rotation was significantly reduced (6.38° ± 7.31° and 8.34° ± 7.92°, respectively; P = .002). Conclusion: The Mulligan knee taping technique successfully reduced knee pain in participants with PFP. This is the first study to establish a link between Mulligan knee taping and the reduction of PFP in conjunction with decreased hip internal rotation and earlier activation of gluteus medius. Clinical Relevance: The Mulligan knee taping technique may benefit the clinical environment by providing an alternative evidence-based treatment plan for PFP.

Lung cancer diagnosis and staging in the minimally invasive age with increasing demands for tissue analysis.

The diagnosis and staging of patients with lung cancer in recent decades has increasingly relied on minimally invasive tissue sampling techniques, such as endobronchial ultrasound (EBUS) or endoscopic ultrasound (EUS) needle aspiration, transbronchial biopsy, and transthoracic image guided core needle biopsy. These modalities have been shown to have low complication rates, and provide adequate cellular material for pathologic diagnosis and necessary ancillary molecular testing. As an important component to a multidisciplinary team approach in the care of patients with lung cancer, these minimally invasive modalities have proven invaluable for the rapid and safe acquisition of tissue used for the diagnosis, staging, and molecular testing of tumors to identify the best evidence-based treatment plan. The continuous evolution of the field of lung cancer staging and treatment has translated into improvements in survival and quality of life for patients. Although differences in clinical practice between academic and community hospital settings still exist, improvements in physician education and training as well as adoption of technological advancements should help narrow this gap going forward.

Juvenile Scleroderma with Isolated CNS Manifestations: Difficulties in Diagnosis and Possible Treatment Plans

Aims: Juvenile scleroderma with isolated CNS manifestations is a rare autoimmune disease. Correct diagnosis is often delayed, evidence-based treatment plans do not exist, and they are currently based on case series. Major clinical symptoms are seizures, paresthesia, and neuropsychological dysfunction.

Balancing Hope and Realism in Family-Centered Care: Physical Therapists’ Dilemmas in Negotiating Walking Goals with Parents of Children with Cerebral Palsy

ABSTRACTThe aims of this study were to explore physical therapists’ beliefs about the value of walking for children with cerebral palsy (CP), how these beliefs inform therapy choices, and to describe how physical therapists engage families in decision-making regarding walking goals. Eight physical therapists who had experience working with children with CP each participated in a qualitative, one-to-one interview exploring their walking-related values, beliefs, and decision-making practices. The physical therapists' accounts demonstrated that they balanced their beliefs and professional expertise with families’ goals in order to preserve families’ hopes and maintain rapport, while also ensuring evidence-based and efficacious treatment plans were implemented. Participants experienced internal conflict when attempting to balance the principles of family-centered care with their personal beliefs and expertise. Further research will augment these findings and contribute to ongoing debates regarding rehabilitation best practices and family-centered care.

Care of Older Adults with Multimorbidity: Geriatric Training for Hospice and Palliative Medicine Providers (P11)

1.Conduct an effective evaluation and create an evidence-based treatment plan for common geriatric conditions applicable across diverse healthcare settings (inpatient palliative care, long-term care, and hospice).2.Describe principles of appropriate prescribing for geriatric patients, including appropriate medication dosing.3.Apply principles of the American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity to clinical practice. According to the ElderCare Workforce, “The current healthcare system is already overwhelmed by demands for geriatric care. Those specializing in the care of older adults cannot meet the current demand let alone the projected needs for eldercare.” Providers in the field of hospice and palliative medicine are increasingly managing the complex needs of geriatric patients with multiple comorbidities, oftentimes with minimal preparation. Those caring for frail older adults with multimorbidities near the end of life often must confront challenging situations: decisions regarding treatments that improve one condition but make another worse; assessing pain and other symptoms in patients that are cognitively impaired; prescribing medications while taking into account changes in pharmacokinetics due to age, and drug-disease and drug-drug interactions. It is imperative for healthcare professionals to meet the needs of this growing vulnerable population. This workshop aims to provide education, resources, and tools to hospice and palliative medicine providers in the principles of care of older adults with complex multimorbities. The workshop will provide an interactive overview of the American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Participants will engage in a PowerPoint game on the topic of pain assessment and treatment in older adults with multimorbidities. Facilitated small groups will discuss the American Geriatrics Society Geriatrics Evaluation and Management Tools (GEM Tools). Workshop facilitators will demonstrate an evolving case highlighting clinical interactions between a provider and an older adult with complex multimorbidities; small groups will then discuss the case demonstration compared with the evidenced-based material outlined in the GEM Tools. The evolving case will cover evidence-based assessment and management of pain, delirium, dementia, behavioral disturbances, falls, and frailty across diverse healthcare settings (inpatient palliative care, long-term care, and hospice).

Improving oncology quality through the implementation of evidence-based clinical pathways in a payer’s oncology network.

161 Background: Physicians and health plans are collaboratively exploring clinical pathway strategies to improve patient outcomes, reduce treatment variation, and reduce oncology cost. One landmark study found that 33.2% of insured patients did not receive guideline cancer therapy. Additional studies have demonstrated that the use of pathways can lower the cost of care and that oncologist participation is a critical element for success. New Century Health (NCH), in partnership with a leading health plan and one of its Midwestern oncology networks, had two quality goals with the implementation of a chemotherapy prior authorization system: review all chemotherapy regimens for all patients and measure treatment plan adherence to evidence-based clinical pathways. Methods: As one component of a mandatory chemotherapy prior-authorization program, an online prior authorization system was used by oncology practices to submit chemotherapy treatment plans to NCH for approval. The system captured detailed patient clinical information and measured compendium and preferred pathway adherence rates. These data were shared with participating oncology practices on a quarterly basis. For analysis, an average Baseline compendium adherence rate was determined reflecting participating practices for six cancer diagnoses (Breast, Colon, Lung, Lymphoma, Multiple Myeloma, and Prostate). The Baseline rate was compared to the Review period rate. Results: A comparison of the Review and Baseline period metrics indicated a statistically significant increase in the level of compendium-based chemotherapy treatment plans submitted by participating providers. Conclusions: Implementation of an oncology prior authorization system that measures compendia-based adherence rates is associated with increased levels of evidence-based chemotherapy treatment plans by participating providers. [Table: see text]

Estimating population size, HIV prevalence and HIV incidence among men who have sex with men: a case example of synthesising multiple empirical data sources and methods in San Francisco

ObjectiveThe number of persons living with HIV/AIDS, the number of new infections and the number of persons at risk for HIV infection are the foundations of evidence-based prevention, treatment and...

An evidence-based assessment and treatment plan for arachnoiditis

Arachnoiditis is a relatively rare and under-diagnosed condition that can affect many patients differently. Most cases are incidentally discovered on radiologic imaging.1 After treating a patient in our institution with lumbar arachnoiditis, we performed a literature review to determine the epidemiology and the most optimal treatment plan for arachnoiditis. The term

Perspective

Ours is an age of unprecedented levels of environmental alteration and biodiversity loss. Beyond the exposure to environmental hazards, conditions such as environmental degradation, biotic impoverishment, climate change, and the loss of ecosystem services create important health threats by changing the ecology of many pathogens and increasing the incidence and/or severity of certain noncommunicable conditions. They also threaten health in the future by weakening the Earth's life support systems.Although physicians remain one of the most often accessed and most trusted sources of information about the environment, there is currently little emphasis on educating medical professionals about these environmental issues. This lack of training reduces the ability of most physicians to be efficient science-public interfaces and makes them ineffective at contributing to address the fundamental causes of environmental problems or participate in substantive environmental policy discussions. This is an important challenge facing medical education today.To turn medical students into effective physician-citizens, an already-overwhelmed medical school curriculum must make way for a thoughtful exploration of environmental stressors and their impacts on human health. The overarching question before medical educators is how to develop the competencies, standards, and curricula for this educational endeavor. To this end, the authors highlight some of the critical linkages between health and the environment and suggest a subset of key practical issues that need to be addressed in order to create environmental education standards for the physician of the future.

Improving Outcomes in Multiple Sclerosis Through Early Diagnosis and Effective Management

CME BACKGROUND Original material is selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME activities on a variety of topics from volume to volume. To obtain credit, read the material and go to PrimaryCareCompanion.com to complete the Posttest and Evaluation online. CME OBJECTIVE After studying this case, you should be able to: Recognize and correctly diagnose MS, especially during the early stages Develop an individualized, evidence-based treatment plan that includes a disease-modifying treatment and any other appropriate interventions to maintain optimal functioning and quality of life Educate patients about their disease and foster their involvement in the treatment process ACCREDITATION STATEMENT The University of North Texas Health Science Center at Fort Worth is accredited by the American Osteopathic Association to award continuing medical education to physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The University of North Texas Health Science Center and the CME Institute of Physicians Postgraduate Press, Inc. The University of North Texas Health Science Center is accredited by the ACCME to provide continuing medical education for physicians. CREDIT DESIGNATION The University of North Texas Health Science Center has requested that the AOA Council on Continuing Medical Education approve this program for 1.0 hour of AOA Category 2B CME credits. Approval is currently pending. The University of North Texas Health Science Center designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DATE OF ORIGINAL RELEASE/REVIEW This educational activity is eligible for AMA PRA Category 1 Credit™ through October 31, 2013. The latest review of this material was September 2012. FINANCIAL DISCLOSURE The faculty for this CME activity, the CME Institute staff, and the University of North Texas Health Science Center staff were asked to complete a statement regarding all relevant personal and financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute and the University of North Texas Health Science Center have resolved any conflicts of interest that were identified. No member of the CME Institute staff or the University of North Texas Health Science Center staff reported any relevant personal financial relationships. Faculty financial disclosure appears with the article. Clinical Points ▪ Patients with MS may present clinically with eye problems, mobility issues, bowel and bladder problems, cognitive deficits, muscle weakness, and fatigue. ▪ The revised diagnostic criteria for MS require the presence of more than 2 silent lesions with dissemination in space and time. ▪ In addition to using diagnostic criteria, clinicians must take a thorough patient history and complete a differential diagnosis. ▪ A referral to a neurologist is necessary if the patient presents with new neurologic symptoms. ▪ Medications are available to manage the symptoms of MS and to slow the disability and prevent exacerbations associated with the disease progression, but at this time there is no cure for MS. Multiple sclerosis (MS) is one of the most prevalent diseases of the nervous system, affecting about 400,000 people in the United States.1 MS appears more frequently in women, in people aged 20 to 50 years, and in people living farther from the equator. As a chronic autoimmune disorder, MS results in demyelination and neurodegeneration. Although the cause is unknown, white blood cells (or T cells) are activated, leave the bloodstream, and infiltrate the blood-brain barrier. In the central nervous system (CNS), the T cells release proinflammatory cytokines, which attract other cells to attack and damage myelin sheaths that protect neuronal fibers, leading to scarring and axonal injury. This damage can affect patients’ mobility, vision, and/or cognitive functioning, especially if left untreated, which underscores the importance of the early recognition of MS. The overall etiology of MS is unclear, but researchers have studied several genes and environmental factors that may increase the risk of this condition. Although MS is not directly hereditary, having a family member with MS does appear to increase the risk.1 Environmental factors may include low exposure to sunlight and vitamin D deficiency, which could explain why areas farther from the equator have more cases of MS. Exposure to certain viruses, such as measles or Epstein-Barr, may also predispose people to developing MS. By following guidelines and completing diagnostic tests to accurately recognize the disorder as early as possible and by initiating appropriate treatments or referring to a specialist, clinicians can greatly reduce the damaging and irreversible course of MS.

Developing consensus treatment plans for proliferative lupus nephritis in childhood-onset systemic lupus erythematous

Purpose The SLE Subcommittee of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) is developing standardized treatment plans for proliferative lupus nephritis (LN) in childhood-onset SLE (cSLE) which will serve as the basis for future comparative effectiveness studies. The Initial Delphi survey revealed wide variability in the treatment of LN in cSLE. This abstract decribes the process of developing standardized evidence-based induction treatment plans for LN in cSLE by using consensus methods.

Health Care Change Ahead: Are You Ready?

Health Care Change Ahead: Are You Ready?

How facial lesions impact attractiveness and perception: Differential effects of size and location

To determine the effect of facial lesion size and location on perceptions of attractiveness and importance for repair. We hypothesized that attractiveness scores and importance for repair would be dependent on lesion size and location. Randomized controlled experiment. Forty-five subjects viewed 35 photographs of normal faces and faces with lesions of different sizes and locations. They rated attractiveness, how disfiguring, how bothered, and how important they considered repair. Iterated factor analysis showed "bothered, disfigured, and important to repair" addressed the same domain, so a disfigured/bothersome/repair factor score (DBRFS) was used. A mixed-effects regression model for attractiveness showed small-central and small-peripheral coefficients were not significantly different, χ(2) (1) = 0.03, P = 1.000; but large-central and large-peripheral differences and small-central and large-peripheral differences were significantly different, χ(2) (1) = 10.34, P = 0.004; and χ(2) (1) = 50.55, P < .001, respectively. DBRFS and attractiveness were poorly correlated (χ = -0.29). A mixed-effects regression for DBRFS showed small-central to large-central and the small-central to large-peripheral coefficients were significantly different, χ(2) (1) = 129.20, P < .001; and χ(2) (1) = 115.25, P < .001; but large-central to large-peripheral coefficients were not, χ(2) (1) = 0.14, P = 1.000. The attractiveness penalty caused by a lesion was correlated with size but not location. Importance to repair was correlated with how disturbing and bothersome it was but not with how the lesion diminished attractiveness. All large lesions and small central lesions were considered important to repair by observers. These results will help us predict the true impact of lesions and support evidence-based treatment plans.

Assessment and management of chronic obstructive pulmonary disease in the emergency department and beyond

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are common, can result in emergency department presentation and often result in hospitalization. After confirming the diagnosis and treating comorbidities, management of severe AECOPD includes bronchodilators, systemic corticosteroids, antibiotics, noninvasive ventilation and, occasionally, endotracheal intubation. Once discharged, delayed follow-up and suboptimal management often occurs. Antibiotics, systemic corticosteroids and optimization of nonpharmacological interventions (e.g., smoking cessation, immunization and pulmonary rehabilitation) are important discharge considerations. Improving linkages to primary providers who adhere to management involving a pharmacological and nonpharmacological evidence-based treatment plan is critical to preventing future AECOPDs, reducing healthcare utilization and maintaining the quality of life of patients following an AECOPD.

Performance Improvement CME: Schizoaffective Disorder

Correctly diagnosing schizoaffective disorder depends on having an accurate history of the patient's signs and symptoms, including documentation from medical and psychiatric records and information gathered from patients and their family members or caregivers. Placing the patient's symptoms within a diagnostic framework helps to differentiate schizoaffective disorder from other psychotic disorders so that an individualized, evidence-based treatment plan can be formulated. Clinicians should monitor treatment adherence, which is closely correlated with treatment outcomes; using multiple, objective measures to assess adherence is optimal. This performance improvement activity provides opportunities to improve strategies for diagnosing schizoaffective disorder, individualizing treatment, and assessing and managing medication nonadherence.

Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines.

To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care. Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed. Philippines. One hundred and forty-three public and private physicians in the Philippines, collected in November 2003-December 2004 and September 2006-June 2007. CPVs administered to physicians. Process quality measures (accounting for the possibility of both over-treatment and under-treatment). Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%). Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.

Communication and Dentistry – an Important Part of the Dentist‐Patient Relationship

It is interesting to note the editorial from Professor Bartold1 and the letter from Dr Lee2 regarding personalized dentistry. Indeed, communication is one of the most salient skills in regards to any clinician-patient relationship but, unfortunately, it is a subject which is readily overlooked and underemphasized, both at a dental school and continuing education level. In contrast, communication, empathy and rapport skills were recognized some years back as an important part of medical training. This was probably introduced as a result of a patient/public perception of a lack of communication in the medical profession and is now compulsory for all students at the University of Melbourne. As a medical student, we had to undergo workshops and participate in role playing exercises to highlight the importance of the skills being taught. Even though these may not be obvious to the student at the time, they can be highlighted or taught so that the student then becomes more aware of what to say and, sometimes, what not to say to a patient and when empathy may be required or appropriate. Therefore, another important skill set is the technique of empathy and sympathy – but particularly empathy. We may not have experienced similar situations to our patients (sympathy) but we should be able to empathize with what the patient is going through, which for some with severe dental phobia is very important in establishing rapport and reducing patient anxiety. These techniques are not only verbal, i.e. ‘That must have been a terrible experience for you’ but also visual or interactive, i.e. giving tissues to a patient who is upset or crying. These represent acknowledgement of the patient’s concerns and may be considered intuitive by some. One can understand, however, with the pressures of clinical dentistry and the heat of the moment, that these things can be overlooked, which is disappointing because such subtle gestures can significantly aide dentist-patient interaction and build rapport. An example of a lack of empathy is the occasional patient one sees in oral and maxillofacial surgical practice requiring a full or partial clearance under general anaesthesia who feels that the referring practitioner has criticized the patient as responsible for their dental condition. Fortunately, this is not a common occurrence. However, it is not our place to judge our patients but to help them through these difficult times. On further questioning of these patients, invariably, they have had a previous bad experience which has affected their whole dental history. Although it is terrible that, in these circumstances, the endpoint of exodontia has been reached, with the use of empathy and rapport we may be able to turn the patient’s experience around to a more positive one that may allow better optimization of their oral health in the future. These communication, empathy/sympathy skills and development of rapport are important in communicating treatment plans and the options for treatment plans to patients. It needs to be explained why a particular treatment plan is suggested or recommended to a patient, and the more evidence based treatment plans are, the better. Central to this is the establishment of informed consent – what are the outcomes of having the treatment proposed but what are the outcomes of not having the treatment. A classic example of this quandary is the management of asymptomatic wisdom teeth. The patient should be informed of the risks of removal and the risks of leaving the teeth in place. Although we can suggest a treatment plan to the patient, sometimes in these situations the treatment plan is actually a decision made between the patient and oral and maxillofacial surgeon, and not a plan dictated by the surgeon alone. Having the patient involved with the decision-making in these situations also empowers the patient, giving them more responsibility over their own actions. Therefore, the four assets made by Bartold1 are extremely pertinent, however so is the order of the points. Communication comes first and foremost. The better communicators we are, the better clinicians we will become.