Guidelines Committee Research Articles

American Gastroenterological Association Institute and College of American Pathologists Quality Measure Development for Detection of Mismatch Repair Deficiency and Lynch Syndrome Management

American Gastroenterological Association Institute and College of American Pathologists Quality Measure Development for Detection of Mismatch Repair Deficiency and Lynch Syndrome Management

Endorsement of: “treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of Sleep Medicine Clinical Practice Guideline” by World Sleep Society

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society’s (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine’s Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM’s CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

Resuscitation After Cardiac Surgery Awareness an Egyptian Multicentre Survey

Abstract Introduction There has been an increasing recognition that cardiac surgery patients have different resuscitative needs than other medical and surgical patients who experience in-hospital cardiac arrest. This was addressed in the 2010 European Resuscitation Council Guidelines and the 2010 American Heart Association Guidelines. However, it’s unknown how widely the guidelines are practiced, or a training protocol is followed in different units in Egypt. Objectives This national survey aims to identify the views and common practice of Egyptian cardiac teams regarding resuscitation after cardiac surgery. Methods A 21-question survey is created based on a prior survey used by the EACTS guidelines committee. Questions included the following topics: Participants demographics, Prevalence of cardiac arrest in the intensive care unit, Cardiac arrest with ventricular fibrillation or non-shockable rhythm, Emergency resternotomy technique, Training and arrest protocols. Survey dissemination was through social media platforms, mobile messaging applications and emails during the time period between November 2020 and January 2021. Results Of 126 responses, 95 were suitable for inclusion. Responses were from 11 centres across Egypt. 68.5% of the respondents were surgeons while cardiac anaesthetists and intensivists formed 12.6% and 18.9% respectively. 76.8% of participants were middle-grade doctors, consultant participation was 23.2%. The median annual number of cases performed in the units was 480 and this ranged from 10 to 3000. The average percentage of cardiac arrests was 7%, Median survival to hospital discharge of all arrests was 33% For patients who go into VF after cardiac surgery, respondents would attempt a mean of 5 shocks with only 24.2% commencing defibrillation shocks before external cardiac massage, while the majority initiating CPR immediately. They would perform emergency resternotomy in a mean time of 12 mins and in 15 mins if the rhythm was not shockable. 56.8% would give 1 mg of adrenaline as soon the cardiac arrest was established, only 6.3% thought that it should be given rarely or not at all. If a surgeon was not immediately available 36.8% of respondents would be happy for any trained personnel to perform the emergency resternotomy while 58.9% expect only the surgeon to perform the resternotomy. 49.4% of the participants have not practised any training to perform an emergency sternotomy. 41% of the respondents state they occasionally practice or talk with the staff about it. Only 9.5% practice regularly on emergency sternotomies. 25% assume current training is enough and does not need modification, while 75% think tailored training is important and staff should be oriented about it in the future. Conclusion An action plan is required to improve the awareness of the junior surgeons with the Cardiac Advanced Life Support Protocol. Proper training of the intensive care staff to implement the protocol in a timely organised manner is needed. Assessment of the rhythm before starting external chest compressions is the corner stone in cardiac patients undergoing cardiac arrest. VF/pVT rhythm, 3 defibrillation shocks are given first; for the non- shockable rhythm, the emergency pacing switched on, this is followed by compressions till resternomtomy. Emergency resternotomy under 5 minutes is the only effective way to save patients with tamponade and extreme hypovolemia.

Surgical Infection Society Guidelines for Total Abdominal Colectomy versus Diverting Loop Ileostomy with Antegrade Intra-Colonic Lavage for the Surgical Management of Severe or Fulminant, Non-Perforated Clostridioides difficile Colitis.

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Guidelines for the monitoring and management of iron overload in patients with haemoglobinopathies and rare anaemias.

Guidelines for the monitoring and management of iron overload in patients with haemoglobinopathies and rare anaemias.

Richter transformation of chronic lymphocytic leukaemia: a British Society for Haematology Good Practice Paper.

Richter transformation of chronic lymphocytic leukaemia: a British Society for Haematology Good Practice Paper.

Risk-based guidelines: Redefining management of abnormal cervical cancer screening results.

In making the 2019 guidelines for risk-based management of patients with abnormal cervical cancer screening tests and cancer precursors, the guidelines committee shifted from results-based to risk-based management recommendations, based on the patient's immediate and 5-year risks of grade 3 or higher cervical intraepithelial neoplasia (CIN 3+). The risk is determined by current and prior screening results (human papillomavirus infection, cytology testing) and the clinical history including age. An immediate 4% or higher risk of CIN 3+ was established as the dividing line between higher and lower risks, and the corresponding management recommendations. This article reviews the changes and their evidence base and discusses clinical implications of the revised guidelines.

CSOG MFM Committee Guideline: Clinical Management Guidelines for Acute Fatty Liver of Pregnancy in China (2021)

Abstract Acute fatty liver of pregnancy (AFLP) is a rare but critical obstetric-specific disease with a high fatality rate, posing a serious threat to the safety of mothers and infants. These guidelines were specially formulated to standardize AFLP clinical pathways and to improve maternal and infant outcomes. Based on a two-round questionnaire survey, the guideline development team identified the following nine clinical issues that clinicians were most concerned about, and developed recommendations for each of them: prenatal outpatient screening for AFLP, diagnosis, preoperative risk assessment, delivery modes and timing, anesthesia methods, perinatal complications, selecting AFLP patients for artificial liver treatment, prognostic assessment, and monitoring during treatment. The guidelines cover the key issues related to AFLP diagnosis and treatment that concern clinicians.

Value for Money in Social Care: The Role of Economic Evidence in the Guideline Development Process of the National Institute for Health and Care Excellence in England

In England, the National Institute for Health and Care Excellence (NICE) has been responsible for developing social care guidelines since 2012. Internationally, it is the first health technology assessment and guideline agency that specifically includes social care. As is the case for NICE’s clinical and public health guidance, social care guidelines comprise recommendations based on the best available evidence of effectiveness and cost-effectiveness. This paper provides an overview of how economic evidence is used within social care guideline development. Firstly, the paper describes the guideline development and quality assurance process, in addition to the roles and responsibilities of the technical team and guideline committee members. Secondly, the paper summarises how economic evidence is reviewed, generated, and used to inform recommendations, with examples given to highlight some of the challenges and opportunities that can be encountered. The paper culminates with proposals for the use of economic evidence in social care in England going forward and makes recommendations for further research in this area. The paper posits that guidelines are an important vehicle for supporting evidence-based practice in social care and that economic evidence is a critical kind of evidence to include. As economic evidence in social care becomes more widely available, it can be increasingly used to produce useful and accessible information for decision makers. Further research is needed to understand the impact of implementing economic evidence-based recommendations in social care practice.

Guidelines for the performance of minimally invasive splenectomy.

Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

Management of cardiovascular complications of bruton tyrosine kinase inhibitors.

Management of cardiovascular complications of bruton tyrosine kinase inhibitors.

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Physician Prescribing and Referral Patterns in Children with Cerebral Visual Impairment.

Cerebral visual impairment (CVI) is the leading cause of visual impairment in the developed world. Providing children with CVI with the appropriate treatment ensures the best possible visual outcome and potentially improves quality of life. The purpose of this study was to determine physician prescribing and visual rehabilitation referral patterns in children with CVI. A retrospective chart review was completed on children with CVI examined at Cincinnati Children's Hospital Medical Center from January 1, 2008, to March 1, 2018. Significant refractive error warranting correction was determined using the American Academy of Ophthalmology Preferred Guidelines and the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee Guidelines. The CVI Range was used as a surrogate to categorize CVI severity. A total of 194 children were included. Sixty-eight (35%) had refractive error warranting correction and were prescribed glasses (group RC), 99 (51%) did not have refractive error warranting correction and were not prescribed glasses (group NRNC), 20 (10%) had refractive error warranting correction but were not prescribed glasses (group RNC), and 7 (4%) did not have refractive error warranting correction but were prescribed glasses (group NRC). There was greater than one-line Snellen equivalent difference between group RC (20/156) and group RNC (20/221). There was greater than six-line Snellen equivalent difference between group NRNC (20/149) and group NRC (20/35). Mean CVI Range score 2 values for each group were 5.9, 4.6, 4.8, and 7.1. Children with less severe CVI were less likely to have significant refractive error but given glasses. Despite significant refractive error, children with more severe CVI were not prescribed glasses. Children with very low visual function were not prescribed glasses as frequently, possibly limiting their visual rehabilitation. Providers should ensure that all children with CVI are correctly prescribed glasses to provide the best possible visual outcome.

Guidance on performance and reporting of high-resolution oesophageal manometry and ambulatory pH monitoring in Singapore

We aimed to provide a practical and evidence-based guide on the indications, performance and reporting of high-resolution oesophageal manometry (HRM) and ambulatory pH monitoring (PHM) in adult patients in Singapore. The guideline committee comprised local gastroenterologists from public and private sectors with particular expertise in aspects of HRM and PHM, and it was tasked to produce evidence-based statements on the indications, performance and reporting of these tests. Each committee member performed literature searches to retrieve relevant articles within the context of domains to which they were assigned. Twelve recommendation statements were created and summarised. Standardising key aspects of HRM and PHM is imperative to ensure the delivery of high-quality care. We reported the development of recommendations for the performance and interpretation of HRM and ambulatory reflux monitoring in Singapore.

The Effect of Connected "Smart" Inhalers on Medication Adherence.

Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent worldwide, and major sources of morbidity. Key barriers to reduce the harm from these conditions are the widespread and related issues of low use of prescribed inhaled therapy, use of medicines differently from that prescribed, suboptimal inhaler technique, and lack of adherence are the action plans. Connected smart inhalers show great potential to improve these issues, and thus outcomes from airways disease. In this mini-review, we considered the published evidence that the use of smart inhalers leads to more doses of preventative treatment being taken on time and with appropriate techniques. We found multiple trials across a variety of settings and age groups where smart inhalers were used with audio-visual reminders and healthcare professional feedback, which substantially improved the number of doses of preventative treatment taken. Trial evidence also supports the use of feedback from smart inhalers in improving true concordance (doses taken correctly and on time), though only for a single type of smart device. The relative lack of study is in contrast with the potential impact of smart inhalers. Major research questions remain unresolved, as who might fund future large-scale studies, how guideline committees may consider them, and how to implement effective solutions.

Transnational by Default: Online Child Sexual Abuse Respects No Borders

Abstract Combatting child sexual abuse on the internet requires a high level of harmonisation of both substantive and procedural laws, as online child sexual abuse is transnational by default: while the transnational nature of child sexual abuse material used to be the exception before the advent of the internet, it is now the rule. In order to prosecute and investigate online child sexual abuse across country borders, states rely heavily on extraterritorial jurisdiction clauses as well as informal and formal law enforcement collaboration channels. This paper analyses existing channels in the opsc, Budapest Convention and Lanzarote Convention, particularly against the background of the recently published crc Committee Guidelines regarding the implementation of the Optional Protocol to the Convention on the Rights of the Child on the sale of children, child prostitution and child pornography (crc/c/156), and provides for concrete guidance on how to ensure that the best interests of the child in the prosecution and investigation of transnational crimes such as online child sexual abuse is the primary consideration.

Perioperative temperature management: a survey of 6 Asia\u2013Pacific countries

BackgroundAnesthesia leads to impairments in central and peripheral thermoregulatory responses. Inadvertent perioperative hypothermia is hence a common perioperative complication, and is associated with coagulopathy, increased surgical site infection, delayed drug metabolism, prolonged recovery, and shivering. However, surveys across the world have shown poor compliance to perioperative temperature management guidelines. Therefore, we evaluated the prevalent practices and attitudes to perioperative temperature management in the Asia–Pacific region, and determined the individual and institutional factors that lead to noncompliance.MethodsA 40-question anonymous online questionnaire was distributed to anesthesiologists and anesthesia trainees in six countries in the Asia–Pacific (Singapore, Malaysia, Philippines, Thailand, India and South Korea). Participants were polled about their current practices in patient warming and temperature measurement across the preoperative, intraoperative and postoperative periods. Questions were also asked regarding various individual and environmental barriers to compliance.ResultsIn total, 1154 valid survey responses were obtained and analyzed. 279 (24.2%) of respondents prewarm, 508 (44.0%) perform intraoperative active warming, and 486 (42.1%) perform postoperative active warming in the majority of patients. Additionally, 531 (46.0%) measure temperature preoperatively, 767 (67.5%) measure temperature intraoperatively during general anesthesia, and 953 (82.6%) measure temperature postoperatively in the majority of patients. The availability of active warming devices in the operating room (p < 0.001, OR 10.040), absence of financial restriction (p < 0.001, OR 2.817), presence of hospital training courses (p = 0.011, OR 1.428), and presence of a hospital SOP (p < 0.001, OR 1.926) were significantly associated with compliance to intraoperative active warming.ConclusionsCompliance to international perioperative temperature management guidelines in Asia–Pacific remains poor, especially in small hospitals. Barriers to compliance were limited temperature management equipment, lack of locally-relevant standard operating procedures and training. This may inform international guideline committees on the needs of developing countries, or spur local anesthesiology societies to publish their own national guidelines.

Water-in-Water Emulsions, Ultralow Interfacial Tension, and Biolubrication

Water-in-Water Emulsions, Ultralow Interfacial Tension, and Biolubrication

Guidelines of the German Association of Engineers for evaluating human work in the digital factory

Occupational Applications Starting with the first part of a guideline in 2001, a group of experts and the associated guideline committee of the German Association of Engineers (VDI) began with the production-logistical evaluation of human work related to simulation procedures and Digital Factory tools. This VDI guideline 3633 part 6 dealt with the first macro-ergonomic procedures available. Published in 2015, in VDI guideline 4499 part 4, micro-ergonomic problems related to human stress from work task were added. Nowadays, the still missing micro-ergonomic evaluation of effects by the work environment is on the way to be published as VDI guideline 4499 part 5. This paper deals with these developments, which are considered state of the art in Germany at least at the time of their publication. In addition, some examples illustrate proven possibilities, but existing gaps are also discussed.

230. Does elevated mean arterial pressure lead to better outcomes in degenerative cervical myelopathy: a prospective, pilot randomized control trial

230. Does elevated mean arterial pressure lead to better outcomes in degenerative cervical myelopathy: a prospective, pilot randomized control trial