Guidelines For Management Of Patients Research Articles

Clinical Practice Guidelines for Assessment and Management of Patients with Borderline Personality Disorder.

Clinical Practice Guidelines for Assessment and Management of Patients with Borderline Personality Disorder.

Highlighting the Treatment Regimens used in COVID-19 epidemic in Iraq with Special Regards to Vitamin D

Coronavirus disease 2019 (COVID-19) is a flu-like infection caused by a novel virus known as Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). After the widespread around the world, it was announced by the World Health Organization (WHO) as a global pandemic. The symptoms of COVID-19 may arise within 2 weeks and the severity ranged from mild with signs of respiratory infection to severe cases of organ failure and even death. Management of COVID-19 patients includes supportive treatment and pharmacological medications expected to be effective with no definitive cure of the disease. The aims of this study are highlighting the management protocol and supportive therapy especially vitamin D and manifesting the clinical symptoms by patients in Iraq. An observational study was conducted on 200 patients and descriptive parameters for data were calculated to analyze the results. The mean age was 42.56±17.49 years and the majority of patients were presented with mild to moderate symptoms (78%). There were many different pharmacological treatment regimens and random doses and duration of vitamin D were taken by the patients. In conclusion, a non-specific treatment protocol was used for the patients without compliance to the national guidelines for management and treatment of COVID-19 patients in Iraq with the administration of a wide range of pharmaceutical agents that required monitoring for their safety and efficacy. Vitamin D is administered in different doses and duration without depending on the basal serum concentration.

566: DESCRIPTIVE ANALYSIS OF OBSTETRIC PATIENTS WITH PULMONARY EMBOLISM AT A SINGLE TERTIARY CENTER

Introduction: Obstetric patients with pulmonary embolism (PE) are at higher risk of severe maternal morbidity and mortality. There is limited data validating current PE scoring systems in the obstetric population. We performed a descriptive study comparing the clinical characteristics and maternal and neonatal outcomes of the PERT consults in all of our female patients in reproductive age, by their pregnancy status. Methods: We identified all female patients in reproductive age (18 to 55) between 1/2019 to 5/2022, and divided by pregnancy status. Electronic medical records were used to collect clinical characteristics and treatment modalities. The primary outcome was survival at 30 days. Secondary outcomes included echocardiogram and CTA findings, admission vital signs, BOVA score procedural and neonatal outcomes. Univariable analysis was performed to compare characteristics and primary outcomes. Results: A total of 106 PERT consults were reported. 6 patients were pregnant. At the time of PE diagnosis the mean gestational age was 23w3d (SD). Two patients were delivered with 1 maternal death. Obstetric patients were younger than non-pregnant patients (33.8 vs. 41.9, p= 0.06). There was no statistical difference in right ventricular (RV) strain by CT (46% vs, p= 0.85), initial heart rate (102 vs. 111, p= 0.28), systolic blood pressure (102 vs. 119, p= 0.08), elevated troponin (50% vs. 61%, p= 0.59), or presence of massive PE (16.7% vs. 16%, p= 0.97). Standard Bova score points were also similar (2.2 vs. 2.1, p= 0.78) corresponding to a grade of 1, low risk. There were more low risk consults in the pregnant group (33.3% vs. 5%, p= 0.007). On initial TTE, there was no difference in RV dilation, function, RVSP, or TAPSE between the groups. Each group also had similar of rates transfer to ICU and interventions on arrival. Survival at 30 days was lower in the pregnant group (83.3% vs. 98%, p= 0.04). Conclusions: Despite similar demographic, hemodynamic, and TTE characteristics between all patients in reproductive age, our study suggest that obstetric patients with PE are at a higher risk of death. Indicating that traditional triage and management guidelines for patients with PE lack reproducibility in the obstetric population. New risk factors need to be identified for outcome predictors in obstetric patients.

Molecular Landscape of Pediatric Thyroid Cancer: A Review.

Thyroid carcinomas (TC) are rare in the pediatric population; however, they constitute the most common endocrine malignancy. Despite some similarities with adult carcinomas, they have distinct clinical behavior and responses to therapy due to their unique pathology and molecular characteristics. The age cut-off used for defining the pediatric age group has been variable across different studies, and the universally accepted recommendations influence accurate interpretation of the available data. Moreover, factors such as radiation exposure and germline mutations have greater impact in children than in adults. Papillary TC is the most common and the most evaluated pediatric TC. Others, including follicular, poorly differentiated and medullary carcinomas, are rarer and have limited available literature. Most studies are from the West. Asian studies are primarily from Japan, with few from China, India, Saudi Arabia and Republic of Korea. This review provides a comprehensive account of the well-established and novel biomarkers in the field, including point mutations, fusions, miRNA, and thyroid differentiation genes. Familial and syndromic associations are also discussed. Current management guidelines for pediatric patients are largely derived from those for adults. An awareness of the molecular landscape is essential to acknowledge the uniqueness of these tumors and establish specific diagnostic and therapeutic guidelines.

HPB P33 Management of Gallstone Disease with Deranged Liver Function Tests – Single Centre Experience

Abstract Background Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones. Methods A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease. Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0. Results Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission. The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC. Conclusions We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines. Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.

Quality of care in patients undergoing coronary angiography with a known risk of contrast-associated acute kidney injury: a retrospective observational study

Iodinated contrast medium is potentially nephrotoxic in susceptible individuals. The aim of this retrospective observational study was to determine the impact of hospital-wide implementation of a guideline to prevent contrast-associated acute kidney injury (CA-AKI) on quality of care and outcomes. A hospital-wide guideline for management of patients known to be at risk of CA-AKI was implemented in April 2019. All patients who underwent coronary angiography at our institution between November 2018 and March 2019 (period 1, before introduction of the guideline) and between August and December 2019 (period 2, after introduction of the guideline) were enrolled. In total, 561 patients were enrolled for period 1 and 578 for period 2. CA-AKI was impossible to diagnose in many patients because of missing post-procedure creatinine control data. Preventive measures were initiated more often in period 2 than in period 1 and in older patients than in younger patients. Preventive measures were not initiated in at least 50% of patients at risk of CA-AKI despite implementation of the guideline. Management of patients at known risk of CA-AKI remains inadequate at our institution even after introduction of a guideline. Physicians should receive organized training in acute kidney injury.

The Neurologist’s Role in Patients with Mild Cognitive Impairment and Mild Alzheimer’s Disease Dementia

AbstractBackgroundAlzheimer’s disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia. Mild cognitive impairment (MCI) affects >10% of US adults over the age of 70 and represents a transitional stage between healthy aging and dementia. Multiple factors influence the path to care through the health system. This study sought to better understand the medical journey of patients with all‐cause MCI and mild AD dementia (ADD) to identify opportunities for improvement.MethodAn anonymous online survey was conducted in a cross‐sectional US‐population of 103 patients with self‐reported diagnosis of MCI/mild ADD, 150 care partners of patients with MCI/mild ADD, and 75 neurologists.ResultIn the most common medical journey for patients (73% of patients), half of patients/care partners (51%) reported they received their diagnosis from a neurologist. The most common reasons patients/care partners initiated discussions with a healthcare provider were symptoms interfering with activities of daily life (51%), symptoms not resolving (46%), encouragement from family or friends (44%), and symptoms worsening in degree of discomfort/frequency (43%). Most patients/care partners (23%) reported receiving a misdiagnosis prior to receiving a formal diagnosis of MCI/mild ADD. Half of neurologists (52%) view themselves as the coordinator of care for patients with MCI/mild ADD; whereas 35% of patients/care partners view them as such.At the time of diagnosis, most neurologists (83%) reported discussing with patients the potential causes of MCI/mild ADD. Most neurologists (84%) reported following American Academy of Neurology guidelines (AAN) for treatment and management of patients with MCI/mild ADD. For ongoing care, treatments most commonly prescribed/recommended by neurologists included mental exercises (84%), general improvements in lifestyle (84%), acetylcholinesterase (AChE) inhibitors (78%), social interaction (75%), and NMDA antagonists (73%).ConclusionNeurologists are often the healthcare provider diagnosing MCI/mild ADD however patients frequently experience misdiagnosis in their medical journey. Neurologists are not viewed as coordinators of care by most patients. Positioning neurologists as coordinators of MCI/mild ADD care and equipping them with the right resources may help patients obtain a diagnosis and treatment sooner.

Asia-Pacific guidelines for managing functional dyspepsia overlapping with other gastrointestinal symptoms.

Contemporary systems for the diagnosis and management gastrointestinal symptoms not attributable to organic diseases (Functional GI Disorders, FGID, now renamed Disorders of Gut-Brain Interaction, DGBI) seek to categorize patients into narrowly defined symptom-based sub-classes to enable targeted treatment of patient cohorts with similar underlying putative pathophysiology. However, an overlap of symptom categories frequently occurs and has a negative impact on treatment outcomes. There is a lack of guidance on their management. An Asian Pacific Association of Gastroenterology (APAGE) working group was set up to develop clinical practice guidelines for management of patients with functional dyspepsia (FD) who have an overlap with another functional gastrointestinal disorder: FD with gastroesophageal reflux (FD-GERD), epigastric pain syndrome with irritable bowel syndrome (EPS-IBS), postprandial distress syndrome with IBS (PDS-IBS), and FD-Constipation. We identified putative pathophysiology to provide a basis for treatment recommendations. A management algorithm is presented to guide primary and secondary care clinicians.

Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial

BackgroundAnxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life. ObjectivesThe Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities. MethodsThe PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups. DiscussionPACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

Assessment of the Nutritional Status and Quality of Life in Chronic Kidney Disease and Kidney Transplant Patients: A Comparative Analysis.

Chronic kidney disease (CKD) can significantly influence a patient's nutritional status, leading to malnutrition. Malnutrition is associated with an increase in morbidity and hospital admissions, as well as a decrease in functional status. All these factors impact emotional, physical, and psychosocial health, leading to a lower quality of life (QOL). The aim of the study was to assess the nutritional status and QOL in patients with CKD compared to patients after kidney transplantation and determine what factors influence nutritional status and QOL in this patient population. The study included 167 patients: 39 pre-dialysis patients-group 1; 65 dialysis patients-group 2; 63 kidney transplant patients-group 3. Patients completed the Kidney Disease Quality of Life questionnaire (KDQoL) and the Mini Nutritional Assessment questionnaire (MNA). A comparative analysis of the QOL of patients in the three study groups showed no statistically significant differences in the overall KDQoL scores. Factors that affected quality of life included the designated group, determined by disease status, MNA score, patient age, and WHR. Nearly 1/3 of patients from groups 2 and 3 were at risk of malnutrition. A systematic assessment of nutritional status and monitoring of QOL should be integrated into the standard management guidelines for CKD patients.

Clinical case of Fabry disease: an interesting finding in cardiac surgery patient

Fabry disease is a lysosomal storage disorder, linked to X chromosome, leading to disruption of glycosphingolipid metabolism due to deficiency of lysosomal α-galactosidase A. The cascade of pathological processes can eventually lead to damage of different organs and systems including cardiovascular system. However, due to polymorphism of clinical manifestations, this disease often remains undiagnosed or diagnosed at terminal multiorgan failure stage. Existing clinical guidelines for management of patients with Fabry disease emphasize the importance of early diagnosis for initiation of specific therapy, as well as need for multidisciplinary approach in treatment of such patients.

Changes in anticancer treatment plans in patients with solid cancer hospitalized with COVID-19: analysis of the nationwide BSMO-COVID registry providing lessons for the future

Solid cancer is an independent prognostic factor for poor outcome with COVID-19. As guidelines for patient management in that setting depend on retrospective efforts, we here present the first analyses of a nationwide database of patients with cancer hospitalized with COVID-19 in Belgium, with a focus on changes in anticancer treatment plans at the time of SARS-CoV-2 infection. Nineteen Belgian hospitals identified all patients with a history of solid cancer hospitalized with COVID-19 between March 2020 and February 2021. Demographic, cancer-specific and COVID-specific data were pseudonymously entered into a central Belgian Society of Medical Oncology (BSMO)-COVID database. The association between survival and primary cancer type was analyzed through multivariate multinomial logistic regression. Group comparisons for categorical variables were carried out through a Chi-square test. A total of 928 patients were registered in the database; most of them were aged ≥70 years (61.0%) and with poor performance scores [57.2% Eastern Cooperative Oncology Group (ECOG) ≥2]. Thirty-day COVID-related mortality was 19.8%. In multivariate analysis, a trend was seen for higher mortality in patients with lung cancer (27.6% versus 20.8%, P= 0.062) and lower mortality for patients with breast cancer (13.0% versus 23.3%, P= 0.052) compared with other tumour types. Non-curative treatment was associated with higher 30-day COVID-related mortality rates compared with curative or no active treatment (25.8% versus 14.3% versus 21.9%, respectively, P < 0.001). In 33% of patients under active treatment, the therapeutic plan was changed due to COVID-19 diagnosis, most frequently involving delays/interruptions in systemic treatments (18.6%). Thirty-day COVID-related mortality was not significantly different between patients with and without treatment modifications (21.4% versus 20.5%). Interruption in anticancer treatments at the time of SARS-CoV-2 infection was not associated with a reduction in COVID-related mortality in our cohort of patients with solid cancer, highlighting that treatment continuation should be strived for, especially in the curative setting.

Clinical and Research Applications of the Electronic Medical Record in Multiple Sclerosis: A Narrative Review of Current Uses and Future Applications.

The electronic medical record (EMR) has revolutionized health care workflow and delivery. It has evolved from a clinical adjunct to a multifaceted tool, with uses relevant to patient care and research. A MEDLINE literature review was conducted to identify data regarding the use of EMR for multiple sclerosis (MS) clinical care and research. Of 282 relevant articles identified, 29 were included. A variety of EMR integrated platforms with features specific to MS have been designed, with options for documenting disease course, disability status, and treatment. Research efforts have focused on early diagnosis identification, relapse prediction, and surrogates for disability status. The available platforms and associated research support the utility of harnessing EMR for MS care. The adoption of a core set of discrete EMR elements should be considered to support future research efforts and the ability to harmonize data across institutions.

Periarticular metal hypersensitivity complications of hip bearings containing cobalt-chromium.

Hip joints with bearings composed of cobalt-chromium alloy (metal-on-metal bearings) have been one of the most widely used implants in joint replacement arthroplasty. Unfortunately, these implants can contribute to a complication called aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), a type IV metal hypersensitivity response around the joint. Consistent with such bearings, increased metal debris can be found in the surrounding fluids and in remote tissues and organs, due to wear and corrosion. It is hypothesized that metal ions released from the prosthesis (including Co2+) can potentially form haptens with proteins such as serum albumin in synovial fluid that in turn elicit ALVAL. Generally, elevated cobalt and chromium levels in synovial fluids may indicate implant failure. However, such measurements cannot be used as a reliable tool to predict the onset of ALVAL. To detect ALVAL, some diagnostic tests, questionnaires and imaging techniques have been used clinically with some success, but a standardized approach is lacking. At present, guidelines for implant usage and patient management are ambiguous and inconsistent across health care authorities. To reduce and better manage the development of ALVAL, further research into the precise molecular mechanism(s) by which ALVAL develops is urgently needed. Identification of diagnostic and prognostic biomarkers for ALVAL is required, as are more standardized guidelines for surgery and patient management.

199 (PB-112) Poster - A systematic review on management of breast cancer patients during the covid 19 pandemic: To assess if there was a clinical delay in treatment and patient perception on delayed treatment. Literature review of the current covid 19 management guidelines for breast cancer patients

Background: During the peak of Covid19 pandemic, healthcare organizations had to restructure to ensure management of covid 19 patients as well as cancer patients. The aim of this study is to assess if there were delays in the management of breast cancer patients in the United States of America, the United Kingdom and the Europe and did the patient report that there were delays in their treatment during the pandemic compared to pre pandemic.

Implementing the evidence: Routine screening for depression and anxiety in primary care

Background: Primary care providers are qualified to treat, diagnose, and manage common mental health issues like anxiety and depression. Anxiety and depression are common among college age students, with the average age of onset occurring in one’s late teens to early 20s. Screening tools are commonly used to recognize patients who may be at risk for anxiety and depression. Purpose: The purpose of this evidence-based practice project was to (a) implement evidence-based guidelines for screening and management of college-aged patients with anxiety and/or depression and (b) to develop an algorithm that describes evidence-based management to guide providers at two student health centers. Methods: All patients who registered for a sick visit or other appointment at the project site were screened for anxiety and depression using two validated tools. An algorithm to help healthcare providers properly assess and better treat anxiety and depression was developed and implemented for this project. Results: A total of 366 patients were screened for depression and anxiety over a 3-month period. Using the created algorithm, patients received education on anxiety and/or depression and a counseling referral. If warranted, patients were prescribed medication therapy for depression and/or anxiety. Conclusion: Screening for anxiety and depression has become the standard of care in primary care clinics. Routine screening tools help healthcare providers identify patients with anxiety and depression. Early identification and diagnosis of anxiety and depression leads to better outcomes in treatment.

Cardiopulmonary exercise testing for patients with anorexia nervosa: a case-control study.

Patients with anorexia nervosa (AN) require appropriate nutrient therapy and physical activity management. Eating disorder treatment guidelines do not include safe, evidence-based intensity criteria for exercise. This study used cardiopulmonary exercise testing (CPX) to evaluate the exercise tolerance of patients with AN. CPX was performed with 14 female patients with AN admitted to a specialized eating disorder unit between 2015 and 2019. Their anaerobic threshold (AT) was determined by assessing their exercise tolerance using CPX and compared with 14 healthy controls (HC). The metabolic equivalents (AT-METS) were compared when AT was reached. We examined factors related to AT (AN-AT) in the AN group, including age, body mass index (BMI), previous lowest weight, minimum BMI, past duration of BMI < 15, exercise history, and ΔHR (heart rate at the AT-resting heart rate). The AT of the AN group (BMI: 15.7 [Mean] ± 1.8 standard deviation [SD]) was significantly lower than that of the HC group (BMI: 19.7 ± 1.8) (AN: 10.0 ± 1.8 vs. HC: 15.2 ± 3.0ml/kg/min, P < 0.001). AT-METS was also significantly lower in the AN group than in the HC group (AN: 2.9 ± 0.52 vs. HC: 4.4 ± 0.91, P < 0.001). AN-AT was highly influenced by ΔHR. This study showed that AT and AT-METS were lower in patients with AN than in HC. Patients with AN should be prescribed light-intensity aerobic exercise, and the current findings may help develop future physical management guidelines for patients with AN. III: Evidence obtained from case-control analytic studies.

Applicability of the European Society of Cardiology Guidelines on the management of acute coronary syndromes to older people with haemophilia A - A modified Delphi consensus by the ADVANCE Working Group.

As people with haemophilia (PWH) receive better treatment and live longer they are more likely to encounter cardiovascular disease (CVD) and other comorbidities. ESC guidelines for the acute management of patients presenting with acute coronary syndrome (ACS) are based on the non-haemophilia population. To review the guidelines and propose relevant adaptations for PWHA without inhibitors who are treated with prophylaxis and present with ACS. As part of the ADVANCE Group, 20 European haemophilia experts used a modified Delphi approach to develop and gain consensus on proposed adaptations of the ESC guidelines for PWHA without inhibitors. Of the 32 Class I recommendations across both guidelines, adaptions were considered necessary and proposed for 15. The adaptions highlight the need to provide sufficient FVIII trough levels at the time of antithrombotic treatment in people with haemophilia A (HA) without inhibitors. Patients receiving emicizumab prophylaxis and requiring oral anticoagulation therapy or combined single antiplatelet plus oral anticoagulation therapy will require additional FVIII replacement therapy. In the absence of high-quality clinical evidence, the combined expert opinion used to develop these adaptions to the current ESC guidelines may help to guide clinicians in their treatment decisions when a PWHA presents with ACS.

Innovative Methodology for Strengthening a Multidisciplinary Team Approach in Cities in Low- and Middle-Income Countries.

Delivering high-quality cancer care to patients through a multidisciplinary team (MDT) care approach remains a challenge, particularly in low- and middle-income countries characterized by fragmented health systems and limited human resources for cancer care. City Cancer Challenge (C/Can) is supporting cities in low- and middle-income countries as they work to improve access to equitable quality cancer care. C/Can has developed an innovative methodology to address the MDT gap, piloted in four cities-Asunciòn, Cali, Kumasi, and Yangon. Collaborating with a network of partners, C/Can and ASCO have developed a package of technical cooperation support focusing on two priority areas that have emerged as core needs: first developing consensus-based, city-wide patient management guidelines for the most common cancers and second, building capacity for the implementation of MDTs in institutions providing cancer care in the city. The real-time application of C/Can's MDT approach in Cali and Asuncion underlined the importance of engaging the right stakeholders early on and embedding MDT guidelines in local and national regulatory frameworks to achieve their sustainable uptake. The results in Cali and Asuncion were essential for informing the process in Yangon, asserting the clear benefits of city-to-city knowledge exchange. Finally, the global COVID-19 pandemic prompted a rapid adaptation of the methodology from an in-person to virtual format; the unexpected success of the virtual program in Kumasi has led to its application in subsequent C/Can cities. The application of C/Can's methodology in this first set of cities has reinforced not only the importance of both resource appropriate guidelines and a highly trained health workforce but also the need for commitment to work across institutions and disciplines.

Emergency colectomies in the NOAC era: a nationwide analysis demonstrating increased complications.

The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies. All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion. Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R2 = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39). Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.