Guidelines For Medical Management Research Articles

Evaluation of solid medical waste management system in Undata Regional General Hospital, Palu city, Central Sulawesi Province, Indonesia

Waste is an environmental problem that is still not fully resolved properly even though the resulting impact has a major effect on environmental pollution, especially solid medical waste. The purpose of this study was to assess the characteristics of solid medical waste at Undata Hospital based on its sources and types, calculate the average weight of solid medical waste generated per day, and evaluate the solid medical waste management system with sorting, packaging, collection and transportation modes in accordance with the criteria of Permen of Environment and Forestry Number 56 of 2015 and Permenkes Number 2 of 2023. This research uses a qualitative approach with a descriptive research type. This research was conducted in August-September 2023. The sampling technique in this study used Purposive Sampling, with 18 informants selected from each unit/room/installation at Undata Hospital, Palu City. Based on the results of the study, it was found that every day Undata Palu Hospital produces domestic waste as much as ± 270 kg / day. The results of the evaluation of the solid medical waste management system at Undata Palu Hospital show that basically it is quite effective but not optimal, because the storage process shows non-compliance with the guidelines for medical waste management by the Ministry of Health Number 2 of 2023, namely storage in TPS which should not be more than 2x24 hours, but in fact the accumulation of solid medical waste is stored for 1 month in the LB3 TPS due to delays in transportation by third parties. This causes a large amount of solid waste in the TPS so that the TPS becomes full and dangerous because the waste undergoes a process of decomposition and decay, which is harmful to the environment and human health. Undata Hospital needs to maximize the procurement of internal medical waste processing equipment (incineration equipment) which needs to be supported by the Environmental Agency and the relevant Health Office to prevent environmental pollution from medical activities.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series.

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

ASSESSING KNOWLEDGE, ATTITUDE, AND PRACTICE OF HEALTHCARE WORKERS REGARDING MEDICAL WASTE MANAGEMENT AT DISTRICT JAMSHORO, SINDH

This study aimed to evaluate the waste management knowledge, attitudes, and practices of three groups of healthcare workers: doctors, nurses, and paramedical staff. A cross-sectional study involved doctors, nurses, and technicians at the National Institute of Cardiovascular Disease (NICVD) and the Syed Abdullah Shah Institute of Medical and Health Science (SASIMS) in Shahwan Sharif, District Jamshoro, Sindh. A convenient non-probability sampling technique was used to select the study participants. A total of 370 healthcare workers consented to be part of the study. The data was obtained through the administration of questionnaires. Data were collected and compiled using Microsoft Excel and analyzed using SPSS version 22.0. This study had 39 (63.2%) males and 34 (36.8 %%) females. The median age of participants was 30.5 years, with a mean of 33.12 ± 8.2 years. The majority of the participants were paramedics (42.7%). They were followed by doctors (34.3%) and nurses (23%). The knowledge of healthcare workers indicated that there was a significant association between the waste categories (p = 0.02), type of waste (p = 0.00), color coding differentiation (p = 0.01), hospital policies (p = 0.00), infection control department (p = 0.03), risk toward healthcare workers (p = 0.00), human anatomical waste (p = 0.01), color-coding container used for wasted sharps and infectious solid waste (p = 0.00), and type of color-coding container (p = 0.00) This study highlights the discrepancies and inadequacies of knowledge and practice of proper healthcare waste management among healthcare workers. Healthcare workers with adequate knowledge were paramedics, doctors, and nurses. All healthcare personnel should have medical waste management guidelines ready and easily accessible.

Abstract 11638: Physician Attitudes Toward Beta Blocker and Antiplatelet Therapy in Spontaneous Coronary Artery Dissection Patients

Background: Spontaneous Coronary Artery Dissection (SCAD) primarily affects younger women and is a cause of acute coronary syndrome for which medical management guidelines and clinical trial data are lacking. Our study assessed physician attitudes toward beta blocker (BB) and antiplatelet therapy (APT) in SCAD. Methods: We conducted an online survey among 165 physicians who treat SCAD. Data were collected about their demographics, BB and APT prescribing practices in hypothetical SCAD patients each with one key difference from the base case, and willingness to randomize patients to BB or no BB and to dual APT [DAPT] (12 months of aspirin and P2Y12 inhibitor, then only aspirin) or single APT [SAPT] (3 months of aspirin, then no APT). Results were analyzed with descriptive statistics and chi-squared test. Results (Table): Of the respondents, 163 (99%) were cardiologists, and 64 (39%) were women. When considering BB at discharge, 88% of physicians would prescribe BB in the base case of an otherwise healthy 49-year-old woman with SCAD, with higher likelihood of prescribing BB in a patient with hypertension or ejection fraction (EF) < 50%. Most physicians (95%) were willing to randomize the base case to BB or no BB. Respondents expressed uncertainty about the benefit of BB use, particularly in patients with normal blood pressure or with EF > 50%. When considering APT at discharge, 38% of physicians would prescribe DAPT, 46% would prescribe SAPT, and 16% would prescribe no APT in the base case. Most physicians (92%) were willing to randomize the base case to the DAPT or SAPT strategies. Physicians expressed concern about inadequate and excessive APT, indicating a range of opinions. Conclusion: Most physicians would prescribe BB and APT at discharge after SCAD, with the type of APT varying widely. Nearly all were willing to randomize patients to BB or no BB and to DAPT or SAPT. Our results suggest clinical equipoise exists for BB and APT use in SCAD and point to the need for clinical trial data.

Current Medical Therapy for Adenomyosis: From Bench to Bedside.

Adenomyosis, characterized by the growth of endometrial tissue within the uterine wall, poses significant challenges in treatment. The literature primarily focuses on managing abnormal uterine bleeding (AUB) and dysmenorrhea, the main symptoms of adenomyosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) and tranexamic acid provide limited support for mild symptoms or symptom re-exacerbation during hormone therapy. The levonorgestrel-releasing intrauterine system (LNG-IUS) is commonly employed in adenomyosis management, showing promise in symptom improvement and reducing uterine size, despite the lack of standardized guidelines. Dienogest (DNG) also exhibits potential benefits, but limited evidence hinders treatment recommendations. Danazol, while effective, is limited by androgenic side effects. Combined oral contraceptives (COCs) may be less effective than progestins but can be considered for contraception in young patients. Gonadotropin-releasing hormone (GnRH) agonists effectively manage symptoms but induce menopausal symptoms with prolonged use. GnRH antagonists are a recent option requiring further investigation. Aromatase inhibitors (AIs) show promise in alleviating AUB and pelvic pain, but their safety necessitates exploration and limited use within trials for refractory patients. This review highlights the complexity of diagnosing adenomyosis, its coexistence with endometriosis and uterine leiomyomas, and its impact on fertility and quality of life, complicating treatment decisions. It emphasizes the need for research on guidelines for medical management, fertility outcomes, long-term effects of therapies, and exploration of new investigational targets. Future research should optimize therapeutic strategies, expand our understanding of adenomyosis and its management, and establish evidence-based guidelines to improve patient outcomes and quality of life.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article.

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

An emerging concern of medical waste management in Rohingya refugee camps at Cox’s Bazar, Bangladesh: existing practice and alternatives

The plight of humanity in refugee camps is an age-old issue, as is the ever-increasing issue of waste management, especially medical waste. Though situations have improved in recent times for refugee camps, the same cannot be concurred about medical waste management, as it increases in amount every day. This is the first study on the refugee camp, which was conducted to assess the status of medical waste management and to quantify and characterize medical wastes disposed of in the Rohingya refugee camp at Cox’s Bazar, Bangladesh. A cross-sectional, qualitative, and quantitative study was done. A total of 499 households, 30 solid waste collectors, 30 HCF workers, and 21 solid waste management (SWM) plant workers were interviewed by KoBo Toolbox. Monthly medical waste collection data from February to June 2022 was also collected. Data collection, processing, and statistical analysis were done using Origin Pro and SPSS software. It was found that the camps did not follow any specific guidelines for medical waste management except for a few segregations in healthcare facilities (HCF). Though 88% of the respondents were aware of the hazardous nature of medical waste, most of them disposed of these wastes in open places (49%) and drains (44%), and 70% did not segregate it from regular waste at the household level. Moreover, 73% of solid waste management workers found medical waste daily in communal bins. The HCF did not keep any records on the production of medical waste. Different types of medical waste were found in communal bins; glass bottles containing medicines were common among them. Data from the material recovery facility (MRF) of this camp showed that the highest amount of medical waste found in the communal bins was in April (65 kg) during the seasonal change from spring to summer and the lowest in February (12.7 kg). Moreover, HCF’s existing medical waste management practices were analyzed with SWOT and DPSIR framework. Based on all the findings, a comprehensive on-site and off-site management plan for medical waste is also proposed here. That will help the concerned prepare a camp medical waste management guideline.

Impact of a targeted temperature management quality improvement project on survival and neurologic outcomes in cardiac arrest patients.

Targeted temperature management (TTM) is recommended for postresuscitation care of patients with sudden cardiac arrest (SCA) and its implementation remains challenging. This study aimed to evaluate the newly designed Quality Improvement Project (QIP) to improve the quality of TTM and outcomes of patients with SCA. Patients who experienced out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) with return of spontaneous circulation (ROSC) and were treated in our hospital between January 2017 and December 2019 were enrolled retrospectively. All included patients received QIP intervention initiated as follows: (1) Protocols and standard operating procedures were created for TTM; (2) shared decision-making was documented; (3) job training instruction was created; and 4) lean medical management was implemented. Among 248 included patients, the postintervention group (n = 104) had shorter duration of ROSC to TTM than the preintervention group (n = 144) (356 vs 540 minutes, p = 0.042); better survival rate (39.4% vs 27.1%, p = 0.04), and neurologic performance (25.0% vs 17.4%, p < 0.001). After propensity score matching (PSM), patients who received TTM (n = 48 ) had better neurologic performance than those without TTM (n = 48) (25.1% vs 18.8%, p < 0.001). OHCA (odds ratio [OR] = 2.705, 95% CI: 1.657-4.416), age >60 (OR = 2.154, 95% CI: 1.428-3.244), female (OR = 1.404, 95% CI: 1.005-1.962), and diabetes mellitus (OR = 1.429, 95% CI: 1.019-2.005) were negative predictors of survival; while TTM (OR = 0.431, 95% CI: 0.266-0.699) and bystander cardiopulmonary resuscitation (CPR) (OR=0.589, 95% CI: 0.35-0.99) were positive predictors. Age >60 (OR= 2.292, 95% CI: 1.58-3.323) and OHCA (OR= 2.928, 95% CI: 1.858-4.616) were negative predictors of favorable neurologic outcomes; while bystander CPR (OR=0.572, 95% CI: 0.355-0.922) and TTM (OR=0.457, 95% CI: 0.296-0.705) were positive predictors. A new QIP with defined protocols, documented shared decision-making, and medical management guidelines improves TTM execution, duration from ROSC to TTM , survival, and neurologic outcomes of cardiac arrest patients.

A Summary of Current Guidelines and Future Directions for Medical Management and Monitoring of Patients with Cystinuria

Cystinuria is the most common genetic cause of recurrent kidney stones. As the result of a genetic defect in proximal tubular reabsorption of filtered cystine, increased urine levels of the poorly soluble amino acid result in recurrent cystine nephrolithiasis. Recurrent cystine stones not only adversely affect the quality of patients suffering from cystinuria but also may result in chronic kidney disease (CKD) from recurrent renal injury. Thus, the mainstay of medical management revolves around prevention of stones. Recently published consensus statements on guidelines for managing cystinuria were released from both the United States and Europe. The purpose of this review is to summarize guidelines for medical management of patients with cystinuria, to provide new insight into the utility and clinical significance of cystine capacity-an assay for monitoring cystinuria, and to discuss future directions for research on treatment of cystinuria. We discuss future directions, including the potential use of cystine mimetics, gene therapy, V2-receptor blockers, and SGLT2 inhibitors, topics which have not appeared in more recent reviews. It is notable that in the absence of randomized, controlled trials, the recommendations cited here and in the guidelines are based on our best understanding of the disorder's pathophysiology, observational studies, and clinical experience.

Real-World Prescribing Patterns for Hypertensive Children in China from 2018 to 2021: A Cross-Sectional Multicenter Study.

Pediatric hypertension become an early marker of cardiovascular diseases, but their antihypertensive drug use patterns are rarely known. To investigate the epidemiological characteristics of pediatric hypertension and the use of antihypertensive drugs in the real world in China. In this study, the demographic, diagnosis, and medication prescription data including the antihypertensive drug types and comorbidities, were analyzed. The antihypertensive drugs use were evaluated according to the Chinese guidelines for hypertension. 1301 prescriptions (number of visits) containing 1880 antihypertensive medical orders were collected. The average number of antihypertensive drugs per prescription was 1.45 (±0.75). The patients aged 16 to 18 (70.18%) accounted for the highest proportion. Kidney diseases (33.28%) were the most common comorbidities. Calcium channel blocker (CCB), angiotensin II receptor blocker (ARB), and β receptor blocker (BB) were the most used antihypertensive drugs. The most frequent monotherapy was CCB, while that of two and three drugs combination were ARB+CCB and ARB+BB+CCB, respectively. Metoprolol (11.44%), nifedipine (10.64%), amlodipine (10.59%), valsartan (6.12%) were the most commonly used antihypertensive drugs. The utilization rate of fixed compound preparations was 7.34%. However, the percentage of recommended antihypertensive drugs was just 14.20%, while the recommended drug combination was 84.93% according to the guidelines. For the first time ever we reported the antihypertensive prescription analysis in children in a large area of China. Our data provided new insights into the epidemiological characteristics and drug use in hypertensive children. We found that the guidelines for medication management in hypertensive children were not routinely followed. The wide use of antihypertensive drugs in children and those with weak clinical evidence raised concerns regarding its rational use. The findings could lead to more effective management of hypertension in children.

COVID-19 Associated Rhino-Orbital-Cerebral Mucormycosis: A Proposed Classification and Treatment Strategies.

Mucormycosis is a rare fungal disease, which was known to affect only immunocompromised hosts, but during the COVID-19 pandemic, a surge in the cases of rhino- orbital-cerebral mucormycosis have been reported; however, the cause is still unknown. As the disease was a rare entity, there was no classification considering the spread and proper management at various stages. Extensive literature search with the terms "mucormycosis," "invasive fungal sinusitis," "COVID-19 associated mucormycosis," and "mucormycosis in COVID-19" was conducted on Pubmed, Scopus, and Embase database, taking into consideration case histories, revealing the site of involvement and treatment based on the disease's extent. Relevant articles were analyzed, and it was found that there is no specific classification of the disease entity and no proper surgical and medical management guidelines to date, Conclusion: This review is an attempt to elaborate on the pathophysiology of mucormycosis and its spread and propose a classification that will help determine policies for the control and prevention of complications, morbidity, and mortality.

Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services.

Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence. To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN. MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia. The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation. The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

The Reckoning: The Return of Genomic Results to 1444 Participants Across the eMERGE3 Network

(Abstracted from Genet Med 2022;24:1130–1138) As increased accessibility to genetic testing contributes to finding more individuals with genetic predispositions to a specific conditions or diseases, National Institutes of Health–sponsored networks grow in importance when considering the identification and subsequent management of these conditions. The American College of Genetics and Genomics (ACMG) designated 59 genes (this is now higher with subsequent versions of the guideline) as highly actionable owing to availability of effective medical management guidelines for individuals with detected disease-causing variants in one of these genes.

Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review.

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Effects of a nurse-led medication self-management intervention on medication adherence and health outcomes in older people with multimorbidity: A randomised controlled trial

BackgroundOlder people with multimorbidity are usually required to manage multiple medications and complex medication regimens. However, clinical guidelines for medication management almost entirely focus on a single disease. Further research is needed to assess the efficacy of medication self-management interventions for older people with multimorbidity. ObjectiveThis study aimed to evaluate the effectiveness of a nurse-led medication self-management intervention on medication adherence and health outcomes in older people with multimorbidity. DesignA single-blind, two-arm randomised controlled trial. SettingsThree community health centres in Changsha, China. ParticipantsOlder people with multimorbidity. MethodsA total of 136 participants were recruited and randomly allocated into either a 6-week nurse-led medication self-management intervention group (n = 67) or usual care group (n = 69). The intervention consisted of three one-on-one educational sessions on medication-related information, motivation and self-management skills and two follow-up phone calls. The primary outcome was medication adherence. Secondary outcomes included medication self-management capacity, treatment experiences, quality of life and utilisation of health care services. Outcomes were measured at baseline, post-intervention and 3-month follow-up. The intervention effects were assessed using generalised estimating equation models. ResultsStatistically significant improvements were found in medication adherence (β = 1.63, p = 0.034), medication knowledge (β = 2.61, p < 0.001), beliefs about harm of medication (β = −1.83, p < 0.001), medication self-efficacy (β = 3.22, p < 0.001) and satisfaction with convenience of medication use (β = 5.02, p = 0.005) for the intervention group compared with the control group immediately post-intervention. Compared with the control group at 3 months follow-up, the intervention group demonstrated significantly greater improvements in medication knowledge (β = 2.26, p < 0.001), beliefs about necessity of medication (β = 2.68, p = 0.002) and concerns about medication (β = −2.44, p = 0.002), medication self-efficacy (β = 1.87, p = 0.015) and medication burden (β = −3.96, p = 0.004). Improved medication adherence was observed in the intervention group at 3 months follow-up compared with baseline, although the differences between the groups were not significant. No statistically significant effects were found on quality of life and utilisation of health care services at either time point. ConclusionsA 6-week medication self-management intervention significantly improved medication adherence immediately post-intervention, suggesting a short-term intervention effect. A longer intervention period and continuous follow-up support may be required to achieve sustained improvements in medication adherence and health outcomes in older people with multimorbidity. RegistrationChiCTR.org.cn (ChiCTR2000030011); Start of recruitment: June 2020.

Korean clinical practice guidelines on biologics and small molecules for moderate-to-severe ulcerative colitis.

Ulcerative colitis (UC), a relapsing-remitting chronic inflammatory bowel disease (IBD), has a variable natural course but potentially severe disease course. Since the development of anti-tumor necrosis factor (TNF) agents has changed the natural disease course of moderate-to-severe UC, therapeutic options for patients who failed conventional treatments are expanding rapidly. IBD clinical trials have demonstrated the potential efficacy and safety of novel biologics such as anti-integrin α4β7 and anti-interleukin-12/23 monoclonal antibodies and small molecules such as a Janus kinase inhibitor. Anti-TNF biosimilars also have been approved and are widely used in IBD patients. Wise drug choices should be made considering evidence-based efficacy and safety. However, the best position of these drugs remains several questions, with limited data from direct comparative trials. In addition, there are still concerns to be elucidated on the effect of therapeutic drug monitoring and combination therapy with immunomodulators. The appropriate treatment regimens in acute severe UC and the risk of perioperative use of biologics are unclear. As novel biologics and small molecules have been approved in Korea, we present the Korean guidelines for medical management of adult outpatients with moderate-to-severe UC and adult hospitalized patients with acute severe UC, focusing on biologics and small molecules.

New England Congenital Cardiology Association Bicuspid Aortopathy Registry (NECCA BAR): A regional preventive cardiovascular care collaboration

BackgroundBicuspid aortic valve is the most common congenital heart defect, and its association with proximal aortic dilation (aortopathy) increases risk for aortic aneurysm and dissection in adults. Maximal aortic root and ascending aortic dimensions are predictors of adverse cardiovascular outcomes. Recent single center data demonstrate medical therapy with beta or angiotensin II receptor blockers tempers aortic growth rates. Although randomized clinical trials may not be feasible, larger population studies would better inform bicuspid aortic valve preventive cardiovascular care. ObjectiveImprove regional pediatric bicuspid aortopathy collaboration with standardized medical management guidelines and patient care registry. MethodsThe New England Congenital Cardiology Association (NECCA) developed consensus-based prophylactic treatment guidelines for bicuspid aortopathy and designed a regional clinical registry (NECCA BAR) to study cardiovascular practice variation and short-term outcomes in subjects with moderate to severe bicuspid aortopathy. Individuals 6 months to 25 years of age with bicuspid aortic valve (all variants) and body surface area-adjusted aortic root or ascending aorta z score ≥ 4.0 SD, and/or absolute dimension ≥4.0 cm, are eligible for inclusion. Standardized bicuspid aortopathy medical management guidelines were established among New England congenital cardiology practices. The primary aims are to compare cardiovascular practice variation by guideline adherence (medical therapy and athletic participation), and evaluate medication effectiveness by comparing rates of annual change in aortic root and ascending aorta dimensions/z scores over 3 years. Additional endpoints include aortic valve disease progression (stenosis/regurgitation), incidence of aortic dissection, surgery, death, and incidence of adverse drug events. ResultsRecruitment in progress; data analysis pending. ConclusionWe describe the development of regional pediatric clinical care guidelines and a patient care registry designed to refine medical management of bicuspid aortopathy.

Heart Failure in Older Adults: Medical Management and Advanced Therapies.

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Knowledge, practice level &amp;amp; attitude towards standard precautions and biomedical waste management among physiotherapy students

Background: Healthcare-associated infections have been reported as a serious problem in healthcare services as these are common causes of illness and mortality among hospitalized patients including healthcare workers. Compliance with the standard precautions has been shown to not only reduce the risk of nosocomial infections but also aids in the prevention of occupational associated infections. Adherence to the precautions reduces the length of hospital stay and speeds up the recovery process. Objective: To assess the knowledge, practice level, and attitude towards standard precautions and biomedical waste management among physiotherapy students. Method: A cross-sectional study with a sample size of 150 physiotherapy students was conducted at the School of Physiotherapy, D.Y Patil University, Navi Mumbai. A self-administered questionnaire was used which was categorized in four domains inquiring about students’ knowledge, implementation, practice and attitude towards standard precautions and bio medical waste management. Student’s knowledge was assessed and the collected data were analyzed using statistical software SPSS version 23 in the form of descriptive statistics. Results: The current study revealed that 77.3% (116 out of 150) & 68.00% (102 out of 150) of the subjects were aware of standard precautions and bio medical waste management guidelines respectively but on an average only 35.00% (52 out of 150) of the subjects had correct knowledge regarding the same. The study also showed that only 37.00% (56 out of 150) and 20.00% (30 out of 150) of the subjects reported correct practices with regards to standard precautions and bio medical waste management respectively. Conclusion: Students were aware of standard precautions and bio medical waste management but had poor knowledge as well as practices. Students find it necessary to follow the guidelines but have insufficient knowledge and agreed on having awareness sessions.

Risk factors for subsequent stone events in pediatric nephrolithiasis: A multi-institutional analysis

Children with nephrolithiasis have a 50% risk of recurrence 3 years following an index urinary stone event. The American Urological Association guidelines for medical management of nephrolithiasis suggest metabolic evaluations be stratified according to risk of future stone events. However, no such risk stratification exists across the pediatric population with urinary stone disease. We aim to assess the risk factors among pediatric patients for a subsequent stone event (SSE). A retrospective review for children <17 years of age with a diagnosis of nephrolithiasis and at least one completed follow-up at two tertiary-care children's hospitals within our state between 2012 and 2017 was performed. Children with known monogenic stone disease were excluded as well as those with follow-up less than 1 year. SSEs following initial diagnosis and treatment for nephrolithiasis were defined as follows: subsequent surgical intervention, new stone on imaging, reported stone passage, or ED evaluation for renal colic. Clinical and demographic factors were compared between patients with and without SSEs and analyzed using univariate and multivariate analyses via Cox proportional hazard models. Survival curves for significant associations for SSEs were generated and evaluated using Log-Rank and Wilcoxon comparisons. A total of 200 patients with median clinical follow-up of 2.9 years were analyzed. Median age was 11.5 years (IQR: 6.0-15.5), with 109 (54.5%) males and 91 (45.5%) females, 94 (47%) of whom had a relevant comorbidity. An SSE occurred in 82 patients (41.0%). Age >12 (HR 2.21, 95%CI 1.42-3.45), reported stone event prior to enrollment encounter (i.e. personal history of nephrolithiasis) (HR 1.82, 95%CI 1.14-2.89), and family history of nephrolithiasis (HR 1.62, 95%CI 1.05-2.51) were associated with SSE on univariate analysis while age >12 (HR 2.09, 95%CI 1.33-3.27) and personal history of nephrolithiasis (HR 1.63, 1.02-2.6) retained significance on multivariable analysis. Survival analysis shows increased risk of recurrence with accumulation of risk factors (Summary Figure). Sensitivity analysis accounting for missing family history data retained significance for all three variables. Adolescent age and a personal history of nephrolithiasis are independent risk factors for SSE in children. Understanding these risk factors and the nature of SSE among the pediatric population can potentially enhance counseling for further metabolic work-up and tailored clinical follow-up.