Guidelines For Management Research Articles

Obstetric management for pregnant women with Klippel-Trenaunay syndrome: A UK case report and review of the literature.

Klippel-Trenaunay Syndrome (KTS) is a rare congenital vascular disorder characterized by extensive capillary and venous malformations that pose unique challenges during pregnancy. This case report discusses the successful management of a 34-year-old pregnant woman with KTS who had two caesarean sections, resulting in the birth of two healthy babies. Despite the lack of evidence-based guidelines for obstetrical management in KTS, a multidisciplinary team collaborated to devise a high-risk thrombosis management plan, involving the use of compression stocking and low molecular weight heparin prophylaxis. The patient's elevated risk of thrombosis, exacerbated during pregnancy, informed the decision of caesarean sections, aligning with finding that in most KTS pregnancies, this method of delivery based on obstetric indications and arteriovenous malformations is chosen. This case highlights the importance of systematic and patient-centered care, advocating for comprehensive obstetric management guidelines to address the unique challenges posed by KTS during pregnancy. Further research is warranted to enhance our understanding and refine guidelines for individuals with vascular abnormalities linked to KTS.

Assessing compliance with national guidelines in diabetes care: A study leveraging data from south Africa's National Health Laboratory Service (NHLS).

Diabetes is a major global health issue. We evaluated compliance to laboratory-based management guidelines for diabetes (type 1 and 2), essential for effective treatment and reducing diabetes-related morbidity and mortality. Our study utilized South Africa's National Health Laboratory Services (NHLS) data, focusing on patients from birth to age 80 years who underwent initial diabetes laboratory testing between January 1, 2012-January 1, 2016. Patients were categorized into type 1 (<30 years) or type 2 (≥30-80 years) diabetes based on age at first diabetes test. National diabetes guidelines recommend blood glucose to be checked every three-six months post laboratory-diagnosis. We employed a sharp regression discontinuity design to estimate the effect of a laboratory-diagnosis of diabetes on the likelihood of having a follow-up laboratory test 24 months post-diagnosis. Among patients with type 2 diabetes, the probability of a diabetes follow-up laboratory test within 24 months was 52.4% for patients presenting above the diabetes diagnosis threshold vs 31.1% for those presenting below. Although the likelihood of repeat testing rose with higher HbA1c and glucose levels, at the diagnostic threshold there was no clinically meaningful difference (risk difference: -2.2%, 95% CI: -3.3%, -1.2%). These results were consistent among patients with type 1 diabetes, those living with and without HIV, and healthcare setting. In a national laboratory cohort, diabetes laboratory-diagnosis did not lead to increased monitoring as recommended in national guidelines. Strategies to improve patient education, healthcare provider communication, and healthcare system support are essential to enhance guideline compliance and overall diabetes management.

DxGoals: A Software Tool for Determining and Analyzing Clinically Meaningful Classification Accuracy Goals for Diagnostic Tests.

To evaluate diagnostic tests for low prevalence conditions, classification accuracy metrics such as sensitivity, specificity, and positive likelihood ratio (PLR) and negative likelihood ratio (NLR) are advantageous because they are prevalence-independent and thus estimable in studies enriched for the condition. However, classification accuracy goals are often chosen without a clear understanding of whether they are clinically meaningful. Pennello (2021) proposed a risk stratification framework for determining classification accuracy goals. A software application is needed to determine the goals and provide data analysis. We introduce DxGoals, a freely available, R-Shiny software application for determining, visualizing, and analyzing classification accuracy goals for diagnostic tests. Given prevalence p for the target condition and specification that a test's positive and negative predictive values PPVand NPV=1-cNPV should satisfy PPV>PPV* and cNPV<cNPV*, DxGoals uses Bayes Theorem to determine equivalent goals for PLR and NLR and implied goals for sensitivity and specificity. When study data are provided, DxGoals analyzes whether the determined goals are met with statistical significance. When comparing 2 tests, DxGoals translates a superiority or noninferiority goals for the differences PPV-p and p-cNPV to equivalent goals for PLR and NLR and analyzes the goals when data are provided. We illustrate DxGoals on tests for penicillin allergy, ovarian cancer, and cervical cancer. The inputs cNPV*,p, and PPV* were informed by clinical management guidelines. DxGoals facilitates determination, visualization, and analysis of clinically meaningful standalone and comparative classification accuracy goals. It is a potentially useful tool for diagnostic test evaluation.

Impact of viral testing on duration of antibiotic treatment and hospitalisation of febrile infants.

To assess the duration of antimicrobial treatment; hospital length of stay; and invasive bacterial infections rates in hospitalised infants following the adoption of a management guideline. Faculty agreed to a standard of 24 h of antibiotic treatment for well-appearing febrile infants with proven viral infection and no growth on bacterial cultures. The outcomes were the duration of hospitalisation and antibiotic treatment of febrile infants less than 8 weeks of age who have enterovirus, parechovirus, respiratory viruses detected. We monitored re-admissions and missed invasive infections. Of the total 1696 infants studied, the median antibiotic treatment duration decreased from 31.5 to 24.8 h in virus-infected infants ≤21 days of age (p = 0.02) and from 26 to 19.7 h in infants 22-56 days of age (p < 0.001). The decrease was less in infants not infected with a virus. No patient had an invasive infection identified after discharge. The implementation of our care standard resulted in reduction in antibiotic treatment duration without known delayed diagnosis of bacterial infections. Infants without a proven viral aetiology may need further study to inform management decisions.

Impact of a national guideline for the management of peripheral arterial disease on revascularization rates in England: interrupted time series analysis.

A national guideline on peripheral arterial disease management in England was issued in August 2012. The impact on revascularization rates was examined and variation with socioeconomic deprivation assessed. Annual hospital admissions for England over 10 years (2008-2009 to 2017-2018) were examined using interrupted time series analysis. A pragmatic approach was used to classify admissions for revascularization into moderate and severe categories. There were 309 839 admissions (56% for moderate peripheral arterial disease), with an overall annual admission rate for revascularization of 86 per 100 000 population aged 25+ years. The rate for moderate peripheral arterial disease marginally increased by 0.29 per 100 000 per year (95% c.i. -0.22 to 0.80) from 2008-2009 to 2012-2013. Following guideline introduction, this rate decreased. The equivalent for severe peripheral arterial disease increased by 1.33 per 100 000 (0.78 to 1.88). Following guideline introduction, this rate plateaued. The change in rate (slope) for moderate peripheral arterial disease of -2.81 per 100 000 per year (-3.52 to -2.10) after guideline introduction was greater than the change in rate for severe peripheral arterial disease of -1.95 per 100 000 per year (-2.73 to -1.17). For moderate peripheral arterial disease, the annual rate in the most socioeconomically deprived category was 15.6 per 100 000 lower in 2017-2018 compared with 2012-2013 (24.3% decrease). The impact progressively diminished with decreasing deprivation. In the least deprived category, the reduction was 5.2 per 100 000 (12.9% decrease). For severe peripheral arterial disease, the decrease was 1.2 per 100 000 (3.1% reduction) with no consistent variation in relation to deprivation. Introduction of the national peripheral arterial disease management guideline in England was associated with a reduction in admission rates for revascularization, especially for moderate peripheral arterial disease, with greater reduction in rates for moderate peripheral arterial disease in more socioeconomically deprived areas. Association, however, does not necessarily imply causation and alternative explanations cannot be ruled out.

Perfusion imaging predicts short-term clinical outcome in isolated posterior cerebral artery occlusion stroke.

Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored. We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short-term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge. The median age of the cohort was 70years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time-to-maximum (Tmax) >6seconds (ρ=.55, p=.004), Tmax >8seconds (ρ=.59, p=.002), Tmax >10seconds (ρ=.6, p=.001), mismatch volume (ρ=.51, p=.008), and cerebral blood volume (CBV) < 34% (ρ=.59, p=.002). Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts.

Germline genetic testing reveals pathogenic variants in uterine serous carcinoma patients

An increase in the risk of developing uterine serous carcinoma (USC) has been observed among BRCA1 and BRCA2 germline pathogenic variant carriers in the published literature. However, routine germline genetic testing is not currently incorporated into USC management guidelines. The primary objective of this study is to define the incidence of germline pathogenic variants identified through genetic counseling referrals for USC patients at our institution. A retrospective cohort study was performed of patients diagnosed with USC at a single institution over a seven-year interval. A total of 91 patients with uterine serous carcinoma were identified. Almost half of the patients were referred to genetic counseling, and just over half of referred patients (24/43, 56%) ultimately underwent germline genetic testing. Pathogenic variants were noted in 12.5% (3/24) of the patients who were tested. Pathogenic mutations were found in BRCA1, BRCA2, and MSH6. Variants of unknown significance (VUS) were seen in 16.6% (4/24) of patients. Based on our findings, we recommend integration of germline testing into the standard management of patients with USC.

Electrical Stimulation Therapies for Public Health Management and Chronic Pain Management

All progressive lung diseases, respiratory disorders, chronic bronchitis, and stubborn (non-reversible) asthma are collectively referred to as chronic obstructive pulmonary disease, or COPD. When a person with COPD maintains their level of muscle strength and mobility, which is crucial for all COPD patients, they can live for several years and profit from life. Conscription is one approach to accomplish physical mobility inside a structured programme, like a physical training programme. It is a part of the COPD management guidelines and has been shown to be a beneficial tool in managing COPD. Neuromuscular electrical stimulation (NMES) has been successfully used as a limited to a small region preparation strategy in seriously impaired patients WHO do not appear to be capable of adhering to strict pulmonary rehabilitation (PR) and/or enduring superior coaching frequencies. In order to evaluate public health concerns and predict the onset of illnesses, the objective of this project is to create an intelligent framework for electrical stimulation therapies for the management of chronic pain and public health.

Safety and efficacy of gout treatments in people with renal impairment

Gout is common in people with chronic kidney disease and in general is sub-optimally managed. Lack of evidence due to the exclusion of people with chronic kidney disease from the majority of clinical trials, concerns about adverse effects and conflicting gout management guidelines all contribute to suboptimal management. Herein we review the evidence for the pharmacological treatment of gout, both flares and long-term urate-lowering, in people with concomitant chronic kidney disease.

The development of Africa's first unified hypertension management guidelines.

Hypertension is a leading cardiovascular risk factor, contributing significantly to morbidity and mortality in Africa. The continent is plagued with a high incidence, coupled with low treatment and control rates. The causes are multifactorial, and among the major causes is an absence of standardized African guidelines for the management of hypertension. Systems of care vary across the continent, with low-income countries having less care than middle-income countries. International guidelines include recommendations for Black populations, but do not account for the cultural and sociodemographic situation of the African. There is therefore the need for African guidelines based on local data to improve the quality of hypertension care. These guidelines will cover the clinical approach to hypertension and its complications at facilities with physicians and nonphysician health workers (NPHW). It will also proffer suggestions for policies to improve the care for patients with hypertension on the continent.

Evaluation and Management of Glenohumeral Instability in Adolescent Patients: An Expert Consensus Statement.

Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known. To develop consensus-based guidelines for the management of glenohumeral instability in adolescents. Consensus statement. A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified. A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability. In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached.

General practitioner support needs to implement cardiovascular disease risk assessment and management guidelines: Qualitative interviews.

Previous research identified numerous barriers to general practitioner (GP) use of cardiovascular disease (CVD) risk guidelines, and it is unclear whether these issues have been resolved. This study explored recent GP experiences. Interviews with 18 GPs in an Australian state with relatively few COVID-19 cases in 2021 were transcribed and coded using a framework analysis approach, with data mapped to five previously identified CVD risk assessment strategies: absolute risk focused, absolute risk adjusted, clinical judgement, passive disregard and active disregard. GPs used various CVD risk calculators to inform clinical decision making, but there were concerns about accuracy, the role of extra risk factors and less 'personalised' assessment. GPs addressed these concerns by requesting additional tests, subjectively adjusting the CVD risk assessment to account for extra risk factors and focusing on individual risk factors. Many barriers to CVD risk assessment guidelines remain. GP support is needed to implement revised guidelines.

American Radium Society Appropriate Use Criteria on Cardiac Toxicity Prevention and Management After Thoracic Radiotherapy

IntroductionThe multidisciplinary American Radium Society Thoracic Committee was assigned to create appropriate use criteria on cardiac toxicity prevention and management for patients undergoing radiotherapy. MethodsA systematic review of the current literature was conducted. Case variants of patients with thoracic malignancies undergoing radiation were created based on presence or absence of cardiovascular risk factors and treatment-related risks assessed by dose exposure to the heart/cardiac substructures. Modified Delphi methodology was used to evaluate the variants and procedures, with less than or equal to three rating points from median defining agreement/consensus. ResultsA total of six variants were evaluated. The panel felt that patients with cardiac comorbidities at high risk for radiation-related cardiac toxicity should undergo a prescreening cardiac-focused history and physical (H&P) examination, electrocardiogram, cardiac imaging including an echocardiogram, and referral to a cardiologist/cardio-oncologist. Recommendations for those without cardiac comorbidities at low risk for cardiac toxicity were to undergo a baseline H&P examination only. Conversely, those without cardiac comorbidities but at high risk for radiation-related cardiac toxicity were recommended to undergo a prescreening electrocardiogram, in addition to a H&P examination. For patients with cardiac comorbidities at low risk for cardiac toxicity, the panel felt that prescreening and postscreening tests may be appropriate. ConclusionsThe American Radium Society Thoracic appropriate use criteria panel has developed multidisciplinary consensus guidelines for cardiac toxicity prevention, surveillance, and management after thoracic radiotherapy based on cardiac comorbidities at presentation and risk of radiation-related cardiac toxicity.

Interlaboratory Evaluation of Bretziella fagacearum Molecular Detection Assays to Guide the eDNA Monitoring of Oak Wilt Disease

ABSTRACTOak wilt disease, caused by the fungus Bretziella fagacearum, can kill mature red oaks within months of infection, severely affecting biodiversity, landscapes, and industries. The disease, originally only present in the United States, was officially reported for the first time in Canada in June 2023. The aim of this study was to suggest a standardized assay and sample processing method to optimize oak wilt detection both in infection centers and ahead of the disease front. Two previously published molecular assays, a Nested PCR and a TaqMan qPCR, were compared to detect B. fagacearum in a variety of samples in a ring trial across five laboratories. Sample types investigated included eDNA from trapped insect vectors (sorted insects and bulk content from traps), infested and healthy oak wood chips, and B. fagacearum conidia dilutions. Results demonstrated that both Nested and TaqMan assays can be used for molecular confirmation of oak wilt, and results are reproducible across different labs. There is a general agreement between both detection assays when testing true‐positive and true‐negative samples. Both methods demonstrated overall good accuracy. The TaqMan assay was more sensitive and detected lower amounts of DNA target. Both tests were 100% specific to oak wood samples, which was the best sample type to use for detection. In general, samples with high Cts were more prompted to yield false negative Nested results. Detecting oak wilt from bulk insect samples was by far more rapid than sorted sap beetles, but resulted in lower detection signals, especially with the Nested assay. The time‐period when the insect traps were set up also had considerable influence on detection results. We hope this study helps to formulate guidelines in oak wilt detection and biosurveillance management.

Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community

BackgroundsFalls affect a significant number of older Australians and present a major challenge to health care providers and health systems with over 380 older Australians hospitalised for a fall each day. ObjectivesThis statement seeks to inform and guide exercise practitioners and health professionals in safe and effective prescription of exercise to prevent falls amongst community-dwelling older people. Exercise prescription to prevent fallsExercise is crucial for preventing falls in older age. Research evidence has identified that programmes which include functional balance and muscle strength training are the most effective in preventing falls. It is also important for exercise to be progressively challenging, ongoing and of sufficient dose to maximise its benefits in reducing falls. Additional (non-exercise) interventions are necessary for people with complex medical conditions, recent hospitalisation and/or particular risk factors not improved by exercise. People at a higher risk of falls may need greater support to undertake safe and effective fall prevention exercise. SummaryGlobal guidelines for fall prevention and management recommend that all older adults should receive advice about exercise to prevent falls. Qualified exercise professionals are well placed to prescribe and supervise functional balance and muscle strength training to older people with varied functional abilities, including those with co-morbidities.

Best practices guidelines in the postoperative management of patients who underwent cervical and lumbar fusions.

There is a lack of standardization in spine surgery in particular, as relates to postoperative care for the most common spine procedures such as cervical and lumbar fusions. The goal of this study was to develop a standardized postoperative treatment protocol for common spine procedures such as cervical and lumbar fusion to reduce unnecessary visits, imaging studies, and create a standard for all spine surgeons to adhere while maintaining quality. We developed a best practices protocol (BPP) for postoperative spine care for anterior cervical diskectomy and fusion (ACDF) and posterior lumbar interbody fusion (PLIF). We compared outcome to retrospective controls (pre-BPP) and a national database [Quality Outcomes Database (QOD)/American Spine Registry (ASR)]. Pre-BPP retrospective controls (n=1,010) were compared to patients enrolled in BPP (n=750). BPP reduced postoperative visits (POV) from 2,201 to 1,061 (52%). Total additional imaging studies computed tomography (CT) and magnetic resonance imaging (MRI) beyond standard X-ray were reduced from 192 studies to 57 (70%); 53% for lumbar fusion and 67% for cervical fusion. Comparing pre-BPP to BPP groups for complications, the number of adverse events was reduced by 52% overall; 45% for lumbar fusion, and 62% for cervical fusion. A subset of BPP patients (n=450) with available data were compared to a national registry QOD and ASR where lumbar and cervical fusion patients showed comparable less lengths of stay, lower 3-month complication rates and lower readmission rates. This is one of the first studies to standardize postoperative spine care as a first step towards creating uniformly accepted models for value-based care (VBC) in spine surgery.

Increased risk of pulmonary embolism and deep vein thrombosis with COVID-19 pneumonia in comparison to influenza pneumonia: insights from the National Inpatient Sample database.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily a respiratory virus causing coronavirus disease 2019 (COVID-19) pneumonia, induces a hypercoagulable state. Previous studies comparing the prevalence of venous thromboembolism (VTE) in patients with COVID-19 pneumonia and those with influenza pneumonia revealed a higher risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) associated with COVID-19 pneumonia. However, these studies have not adequately accounted for the severity and acuity of the presenting viral pneumonia. In this retrospective study, we rigorously adjusted for critical illness using a nationally representative dataset to investigate whether COVID-19 pneumonia is independently linked to a higher risk of PE and DVT. After comprehensive multivariate adjustment, our findings demonstrated that patients with COVID-19 pneumonia maintained significantly higher odds of developing acute inpatient PE [adjusted odds ratio (aOR): 2.48; 95% confidence interval (CI): 2.16-2.86; P<0.01] and DVT (aOR: 1.66; 95% CI: 1.41-1.96; P<0.01) during the early pandemic compared to patients with influenza pneumonia. Furthermore, we identified congenital heart disease and malnutrition as novel risk factors for acute PE in COVID-19 patients. Our study suggests that the higher prevalence of acute inpatient PE over DVT in patients with COVID-19 pneumonia may support a "thrombus in situ" mechanism of SARS-CoV-2-mediated pulmonary thrombosis. Consequently, clinicians should maintain a high index of suspicion for PE, even in the absence of DVT, among patients with COVID-19 pneumonia and should follow evidence-based guidelines for diagnosis and management.

Sustainable Development of Digital Cultural Heritage: A Hybrid Analysis of Crowdsourcing Projects Using fsQCA and System Dynamics

Cultural heritage crowdsourcing has emerged as a promising approach to address the challenges of digitizing and preserving cultural heritage, contributing to the sustainable development goals of cultural preservation and digital inclusivity. However, the long-term sustainability of these projects faces numerous obstacles. This study explores the key configurational determinants and dynamic evolutionary mechanisms driving the sustainable development of cultural heritage crowdsourcing projects, aiming to enhance their longevity and impact. An innovative integration of fuzzy-set qualitative comparative analysis (fsQCA) and system dynamics (SD) is employed, drawing upon a “resource coordination–stakeholder interaction–value co-creation” analytical framework. Through a multi-case comparison of 18 cultural heritage crowdsourcing projects, we identify necessary conditions for project sustainability, including platform support, data resources, knowledge capital, and digitalization performance. The study reveals multiple sufficient pathways to sustainability through configurational combinations of participant motivation, innovation drive, social capital, and social impact. Our system dynamics analysis demonstrates that crowdsourcing project sustainability exhibits significant nonlinear dynamic characteristics, influenced by the interaction and emergent effects of the resource–participation–performance chain. This research offers both theoretical insights and practical guidance for optimizing crowdsourcing mechanisms and sustainable project operations, contributing to the broader goals of sustainable cultural heritage preservation and digital humanities development. The findings provide a roadmap for policymakers and project managers to design and implement more sustainable and impactful cultural heritage crowdsourcing initiatives, aligning with global sustainability objectives in the digital age.

Trends in Utilization and Cost of Nonpharmacological Pain Therapies in the United States Under Medicare Part B, 2000-2022.

Background: Many clinical practice guidelines for management of pain disorders now favor first-line use of nonpharmacological therapies (NPT). However, Medicare coverage of NPT is limited. Methods: Using a serial cross-sectional design, we examined temporal trends in the utilization and cost of NPT procedures commonly used to treat pain under Medicare. Results: Utilization and costs for physical therapy increased while those for spinal and osteopathic manipulation declined. Discussion: Future research on NPT under Medicare should focus on equity of patient access and comparative outcomes.

2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease: An Executive Summary.

2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease: An Executive Summary.