Consensus Guidelines For Management Research Articles

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Enduring Consensus Guidelines for Cervical Cancer Screening and Management: Introduction to the Scope and Process.

The Enduring Consensus Cervical Cancer Screening and Management Guidelines (Enduring Guidelines) effort is a standing committee to continuously evaluate new technologies and approaches to cervical cancer screening, management, and surveillance. The Enduring Guidelines process will selectively incorporate new technologies and approaches with adequate supportive data to more effectively improve cancer prevention for high-risk individuals and decrease unnecessary procedures in low-risk individuals. This manuscript describes the structure, process, and methods of the Enduring Guidelines effort. Using systematic literature reviews and primary data sources, risk of precancer will be estimated and recommendations will be made based on risk estimates in the context of established risk-based clinical action thresholds. The Enduring Guidelines process will consider health equity and health disparities by assuring inclusion of diverse populations in the evidence review and risk assessment and by developing recommendations that provide a choice of well-validated strategies that can be adapted to different settings. The Enduring Guidelines process will allow updating existing cervical cancer screening and management guidelines rapidly when new technologies are approved or new scientific evidence becomes available.

Recommendations for Use of p16/Ki67 Dual Stain for Management of Individuals Testing Positive for Human Papillomavirus.

The Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee developed recommendations for dual stain (DS) testing with CINtec PLUS Cytology for use of DS to triage high-risk human papillomavirus (HPV)-positive results. Risks of cervical intraepithelial neoplasia grade 3 or worse were calculated according to DS results among individuals testing HPV-positive using data from the Kaiser Permanente Northern California cohort and the STudying Risk to Improve DisparitiES study in Mississippi. Management recommendations were based on clinical action thresholds developed for the 2019 American Society for Colposcopy and Cervical Pathology Risk-Based Management Consensus Guidelines. Resource usage metrics were calculated to support decision-making. Risk estimates in relation to clinical action thresholds were reviewed and used as the basis for draft recommendations. After an open comment period, recommendations were finalized and ratified through a vote by the Consensus Stakeholder Group. For triage of positive HPV results from screening with primary HPV testing (with or without genotyping) or with cytology cotesting, colposcopy is recommended for individuals testing DS-positive. One-year follow-up with HPV-based testing is recommended for individuals testing DS-negative, except for HPV16- and HPV18-positive results, or high-grade cytology in cotesting, where immediate colposcopy referral is recommended. Risk estimates were similar between the Kaiser Permanente Northern California and STudying Risk to Improve DisparitiES populations. In general, resource usage metrics suggest that compared with cytology, DS requires fewer colposcopies and detects cervical intraepithelial neoplasia grade 3 or worse earlier. Dual stain testing with CINtec PLUS Cytology is acceptable for triage of HPV-positive test results. Risk estimates are portable across different populations.

Cesarean Scar Ectopic Pregnancy: Experience From Benghazi Medical Center, 2022

Background: Cesarean scar pregnancy (CSP) is a rare consequence of a previous cesarean delivery and a new type of ectopic pregnancy, but it is life-threatening if unrecognized and inadequately managed. Despite the rising incidence of CSP, there are no consensus or evidence-based guidelines for management. Aims: To review risk factors, clinical features, diagnostic methods, and management of women with CSP at Benghazi Medical Center. Materials and methods: A descriptive-case series study of CSP cases between the Ist of March 2018 and Ist of April 2022.. Data collected retrospectively. The data included demographics, presenting symptoms and signs, ultrasound findings, treatment used, and any complications. Results: The total number of ectopic pregnancies in period between 1st March 2018 and 1st April 2022 was 262, ten women (3.82%) were diagnosed as scar ectopic, The women's ages ranged from 28 to 47 years, about 60% had three or four previous cesarean scars, abdominal pain with vaginal bleeding was in 30% of the cases, while 60% of patients were asymptomatic and all patients were stable during the diagnosis, except for one case that had signs of shock. ultrasound finding was 80% presence of gestational sac implanted low near the previous scar; initial diagnosis was delayed by 50%. The management was laparotomy and gestational sac excision in four cases that did not require further treatment, dilatation and uterine evacuation were done in two cases that required use of uterine balloon to control bleeding and further use of methotrexate In one case (10%), systemic methotrexate alone was effective. Severe bleeding was seen among 60% of women, and 20% underwent hysterectomy. The complications were significantly (P< 0.05) more common among women with high parity and also in cases where there was no intervention during the diagnosis. Conclusion: A previous uterine scar is the main risk factor for CSP; there is no specific clinical feature for CSP; ultrasound is used for the diagnosis; surgical management appears to be a better option, serious complications were seen mainly when no intervention was done during the diagnosis.

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Current State of Perioperative Buprenorphine Management-A National Provider Survey.

Buprenorphine maintenance for opioid use disorder (OUD) can present potential challenges for acute postoperative pain management. Provider practice and consistency of buprenorphine management strategies within institutions are unknown. This study aims to identify how providers nationwide manage patients on buprenorphine when they present for elective surgery. A prospective survey of anesthesiologists was performed nationwide between November 2021 and March 2022. Survey respondents were selected from academic institutions identified using public databases and were also distributed to online social media platforms where members are required to verify medical licensure and hospital affiliation. Survey results were calculated and interpreted as the percentage rate of response. Survey invitations were sent to 190 institutions and returned 54 responses (28% response rate). An additional 12 completed surveys were obtained from online social media distribution resulting in 66 responses. Only 36% of respondents reported an established protocol for perioperative management of buprenorphine at their institution. Regarding consistency of buprenorphine management within institutions, the majority of respondents endorsed buprenorphine continuation without dose reduction in procedures where minimal pain was anticipated. However, there was a large discrepancy in buprenorphine management for surgeries with moderate-severe pain. Perioperative dosing frequency of buprenorphine was also inconsistent. The majority of institutions surveyed do not have an established protocol for perioperative buprenorphine management. In addition, there is provider variability in buprenorphine dosing for procedures with moderate-severe pain. This study highlights the need for dissemination of consensus guidelines for buprenorphine management.

A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines.

The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results. To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines. A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent. Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms. The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

Current pain management practices for preterm infants with necrotizing enterocolitis: a European survey

BackgroundNecrotizing enterocolitis (NEC) is a highly painful intestinal complication in preterm infants that requires adequate pain management to prevent short- and long-term effects of neonatal pain. There is a lack of international guidelines for pain management in NEC patients. Therefore, this study aims to describe current pain management for NEC patients in European neonatal intensive care units (NICUs).MethodsAn online survey was designed and conducted to assess current practices in pain management for NEC patients in European NICUs. The survey was distributed via neonatal societies, digital platforms, and professional contacts.ResultsOut of the 259 responding unique European NICUs from 36 countries, 61% had a standard protocol for analgesic therapy, 73% assessed pain during NEC, and 92% treated NEC patients with intravenous analgosedatives. There was strong heterogeneity in the used pain scales and initial analgesic therapy, which mainly included acetaminophen (70%), fentanyl (56%), and/or morphine (49%). A third of NICU representatives considered their pain assessment adequate, and half considered their analgesic therapy adequate for NEC patients.ConclusionsVarious pain scales and analgesics are used to treat NEC patients in European NICUs. Our results provide the first step towards an international guideline to improve pain management for NEC patients.ImpactThis study provides an overview of current pain management practices for infants with necrotizing enterocolitis (NEC) in European neonatal intensive care units.Choice of pain assessment tools, analgosedatives, and dosages vary considerably among NICUs and countries.A third of NICU representatives were satisfied with their current pain assessment practices and half of NICU representatives with their analgesic therapy practices in NEC patients in their NICU.The results of this survey may provide a first step towards developing a European pain management consensus guideline for patients with NEC.

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

Time trends assessment of cervical cancer characteristics in Guangzhou, 2010–2021: Is the age at diagnosis increasing over time?

Cervical cancer remains a great challenge to global health, especially in low and middle income countries. A study estimated an occurrence of 111,000 cases of cervical cancer and 34,000 related deaths in 2015 in China [ [1] Cao M. Li H. Sun D. Chen W. Cancer burden of major cancers in China: a need for sustainable actions. Cancer Commun (Lond). 2020; 40: 205-210https://doi.org/10.1002/cac2.12025 Crossref Scopus (132) Google Scholar ]. Persistent infection of high-risk subtypes of the human papillomavirus (HPV) is known to be the main cause of cervical cancer. HPV vaccination and cervical screening programs are effective means to eliminate cervical cancer. However, HPV vaccine was only first approved in China in 2017 for women 9–45 years old. Besides that, the current cervical cancer screening program in China targets women between 35 and 64 years old, and cessation of routine cervical cancer screening in adequately screened women at the age of 65 years is recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP) [ [2] Perkins R.B. Guido R.S. Castle P.E. Chelmow D. Einstein M.H. Garcia F. et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020; 24: 102-131https://doi.org/10.1097/LGT.0000000000000525 Crossref PubMed Scopus (320) Google Scholar ]. These conditions leave older women at an unchanged risk of cervical cancer.

G-CSF Administration Is Associated with Worse Treatment Response and Survival after CAR T-Cell Therapy

Background: Chimeric antigen receptor T (CAR T)-cell therapy has led to unprecedented responses in patients with relapsed/refractory non-Hodgkin's lymphoma and heavily treated multiple myeloma. Despite impressive and relatively durable response rates, CAR T-cell therapy does not work for all patients and most patients tend to relapse. Recent correlative data from patients with decade-long remissions after CAR T-cell therapy showed that the initial response phase is driven by CD8+ CAR T-cells with a long-term remission phase dominated by CD4+ CAR T-cell phenotypes [Melenhorst JJ et al. Nature, 602(7897), 503-509]. Preclinical data has shown that G-CSF directly influences the effector function of cytotoxic CD8+ T cells and may lead to reduced reactivity [Franzke A et al. (2003) Blood, 102(2), 734-739 & Bunse CE et al. (2016). Clinical & Experimental Immunology, 185(1), 107-118]. Studies outlining the prognostic impact of G-CSF among patients treated with CAR T-cell therapy remain limited. There are no consensus guidelines for management of prolonged cytopenia using growth factor support, with wide variations in guiding practice amongst physicians or institutions. In this study, we recorded the utilization of G-CSF in a cohort of 80 consecutive patients treated with CAR T-cell therapy at our institution. We analyzed its potential impact on treatment response and survival after CAR T-cell therapy. Methods: This is a retrospective analysis of consecutive adult patients with an underlying B cell non-Hodgkin lymphoma (n=60) or multiple myeloma (n=20) treated with CAR T-cell therapy from 2016-2022. Baseline characteristics, laboratory measurements and clinical events following CAR T-cell therapy were collected by review of patients' electronic medical record. Medication records were reviewed to determine exposure to G-CSF, starting on day +1 through day +30 following CAR T-cell infusion. We used a chi square test or Fisher's exact test to compare proportions between groups. We calculated unadjusted and adjusted hazard ratios (HR) and 95% confidence intervals (CI) for overall survival (OS) and progression-free survival (PFS) and compared survival between the groups using the Mantel Cox log rank test. Results: Of 80 patients treated with CAR T-cell therapy, 76.2% (61/80) developed neutropenia with nadir ANC <500/uL before day +30. The median time to onset of neutropenia was +1 day, and 26.2% (21/80) of patients were neutropenic at the time of CAR T-cell infusion. In this cohort, 68.7% (55/80) of patients received G-CSF for management of severe neutropenia between days +1 and +30. Median time to initiation of G-CSF was 4 days (range 1-23 days) after treatment. Use of G-CSF did not decrease median length of stay compared to patients who did not receive G-CSF (20.5 vs 19 days). Administration of G-CSF was associated with worse treatment response at day 30, with only 65.5% (36/55) of patients in the G-CSF group attaining complete or partial response, compared to 88% (22/25) of patients in the non-G-CSF group with partial response or better (p=0.04). Patients who received G-CSF had significantly worse PFS (4.43 vs 63.1 months; p=0.01 with HR 2.23 95% CI 1.2 to 4.123 and OS (13.7 vs 67.8 months; p=0.001 with HR 3.62 95% CI 1.88 to 7.02) compared to patients not treated with G-CSF. On multivariate analyses, differences in survival with G-CSF use persisted despite adjusting for prior lines of therapy, HSCT status, development of CRS and underlying disease for PFS (adjusted HR 3.66; 95% CI 1.67-8.03) and OS (adjusted HR 4.66; 95% CI 1.70-12.76). Although patients with underlying myeloma had worse median OS when compared to patients with lymphoid malignancy (10.8 vs 24.8 months, respectively), both groups had significantly worse OS when compared to patients in the non-G-CSF group (67.8 months, p=0.001 and p=0.002 respectively). Among patients who received G-CSF, three or more prior lines of therapy was associated with worse OS (11.5 months), but patients who received <3 prior lines of therapy also had a significantly worse OS compared to the non-G-CSF group (p=0.03; HR 3.3 with 95% CI 1.1 to 9.8). Conclusion: In this single institution retrospective study, administration of G-CSF within 30 days of CAR T-cell infusion is associated with worse treatment response, PFS and OS irrespective of underlying disease, prior lines of therapy or HSCT status. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Consensus guidelines for sarcopenia prevention, diagnosis and management in Australia and New Zealand.

Sarcopenia is an age-associated skeletal muscle condition characterized by low muscle mass, strength, and physical performance. There is no international consensus on a sarcopenia definition and no contemporaneous clinical and research guidelines specific to Australia and New Zealand. The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force aimed to develop consensus guidelines for sarcopenia prevention, assessment, management and research, informed by evidence, consumer opinion, and expert consensus, for use by health professionals and researchers in Australia and New Zealand. A four-phase modified Delphi process involving topic experts and informed by consumers, was undertaken between July 2020 and August 2021. Phase 1 involved a structured meeting of 29 Task Force members and a systematic literature search from which the Phase 2 online survey was developed (Qualtrics). Topic experts responded to 18 statements, using 11-point Likert scales with agreement threshold set a priori at >80%, and five multiple-choice questions. Statements with moderate agreement (70%-80%) were revised and re-introduced in Phase 3, and statements with low agreement (<70%) were rejected. In Phase 3, topic experts responded to six revised statements and three additional questions, incorporating results from a parallel Consumer Expert Delphi study. Phase 4 involved finalization of consensus statements. Topic experts from Australia (n=62, 92.5%) and New Zealand (n=5, 7.5%) with a mean±SD age of 45.7±11.8years participated in Phase 2; 38 (56.7%) were women, 38 (56.7%) were health professionals and 27 (40.3%) were researchers/academics. In Phase 2, 15 of 18 (83.3%) statements on sarcopenia prevention, screening, assessment, management and future research were accepted with strong agreement. The strongest agreement related to encouraging a healthy lifestyle (100%) and offering tailored resistance training to people with sarcopenia (92.5%). Forty-seven experts participated in Phase 3; 5/6 (83.3%) revised statements on prevention, assessment and management were accepted with strong agreement. A majority of experts (87.9%) preferred the revised European Working Group for Sarcopenia in Older Persons (EWGSOP2) definition. Seventeen statements with strong agreement (>80%) were confirmed by the Task Force in Phase 4. The ANZSSFR Task Force present 17 sarcopenia management and research recommendations for use by health professionals and researchers which includes the recommendation to adopt the EWGSOP2 sarcopenia definition in Australia and New Zealand. This rigorous Delphi process that combined evidence, consumer expert opinion and topic expert consensus can inform similar initiatives in countries/regions lacking consensus on sarcopenia.

Clinical practice guidelines for the management of patients with complex regional pain syndrome: a systematic appraisal using the AGREE II instrument.

Aim: Complex regional pain syndrome (CRPS) is a debilitating, painful condition of limbs that often arises after an injury and is associated with significant morbidity. Materials & methods: The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, used to assess the quality of clinical practice guidelines (CPGs), was used to evaluate sevenCRPS management guideline. Results: Out of the sevenCPGs evaluated using the AGREE II instrument, only one from Royal College of Physicians was found to have high-quality consensus guidelines for diagnosis and management of CRPS. Conclusion: Future CPGs should be backed by systematic literature searches, focus on guidelines clinical translation into clinical practice and applicability to the desired patient population.

Collaborative approach to the emergency management of post-thyroidectomy haematoma

Background: The risk of haemorrhage after thyroid surgery is 1–5%. Our local incidence at Royal Surrey Hospital over the past 2 yr is 2%. As haematoma develops, pressure in the neck increases leading to impaired venous return from the head, causing progressive laryngeal oedema. Opening the neck wound allows immediate release of pressure, which should prevent worsening of the oedema and help optimise intubation conditions. Difficult Airway Society (DAS), British Association of Endocrine and Thyroid Surgeons (BAETS), and Ear, Nose and Throat UK (ENT UK) developed consensus guidelines for early recognition and management of haematoma after thyroid surgery, along with a series of recommendations that would ‘improve patient safety by identifying key areas in clinical management, training and institutional preparedness’.1 Methods: Initially we wanted to assess our local policies and awareness of the guidelines, and any specific issues related to post-thyroidectomy haematoma management in our hospital. We surveyed the multidisciplinary team (MDT) including PACU nurses, anaesthetists, and ENT (ear, nose, throat) surgeons, to assess their knowledge of the clinical signs of impending airway compromise secondary to haematoma development and the key steps in its management. We also reviewed the postoperative areas for the presence of appropriate equipment to manage a post thyroidectomy haematoma. Results: Our hospital does not currently have a specific ‘post-thyroidectomy haematoma management’ box in any of the postoperative areas or wards, nor does any equipment accompany the patient out of theatre for this eventuality. Most members of the MDT involved with these patients had not received any formal training in post-thyroidectomy haematoma recognition or management and were not aware of any guidelines covering this scenario. The PACU nurses knew the most important symptoms of impending airway compromise, but not all were aware of the more subtle signs (e.g. anxiety). More ENT surgeons (85%) were aware of the guidelines than anaesthetists (33%). Of the anaesthetists, 75% were aware that part of the management includes releasing the sutures/clips; however, only 25% knew where to find the appropriate equipment to carry this out. All ENT surgeons were aware of the appropriate management; however, they highlighted the importance of formal teaching given that often only the skin was opened and not the deeper tissues, which would not necessarily treat the problem. Conclusions: Going forward, we plan to introduce printed guidelines (DESATS [Difficulty swallowing; Early warning score; Swelling; Anxiety; Tachypnoea; Stridor] for monitoring plus management of suspected haematoma) to accompany the patient from theatre to PACU and the ward. We will also bring in an emergency box with the SCOOP (skin exposure, cut sutures, open skin, open muscles, pack wound) guideline included in the postoperative areas. Finally, we are arranging appropriate MDT education/training sessions on the guidelines and the role of the emergency box. We aim to then re-survey the MDT to ascertain their confidence managing these cases, and to identify any problems with the use of the guidelines or the box. 1.Iliff HA, El-Bogdadhly K, Ahmad I, et al. Anaesthesia 2022: 77; 82–95

Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients.

Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent. The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time. This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models. 138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60years (interquartile range 55-67; 90 men) and median follow-up time was 19.6months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43). In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.

Risk-Based Cervical Consensus Guidelines: Methods to Determine Management if Less Than 5 Years of Data Are Available.

In the 2019 ASCCP Risk-Based Management Consensus Guidelines, clinical management decisions are based on immediate and 5-year cervical intraepithelial neoplasia (CIN) 3+ risk estimates. However, data for technologies other than human papillomavirus testing and cytology may be limited to clinical trials and observational studies of shorter duration than 5 years. To enable decisions about 1- or 3-year intervals, 3-year CIN 3+ risk equivalents to 5-year CIN 3+ risk thresholds were generated. We examined screening test result scenarios around the 5-year risk thresholds of 0.15% and 0.55% and calculated the average percent increase in CIN 3+ risk from 3 to 5 years. Using this average increase, we obtained estimates of corresponding risk thresholds at 3 years. We then validated whether use of the 3-year risk threshold would have resulted in equivalent management per the 2019 recommendations. Around the 5-year CIN 3+ risk threshold of 0.55%, the average increase in risk from 3 to 5 years was 0.16%. Therefore, the equivalent threshold for 3-year risk was estimated as 0.39%. We found no difference in recommendations to return in 1 or 3 years using the 3-year or 5-year risk thresholds in 66 of the 67 scenarios (98.5%) in follow-up in 2019 guidelines. In this methodological addendum, the Enduring Guidelines Committee adopted the use of the 0.39% 3-year CIN 3+ risk threshold as equivalent of the 0.55% 5-year CIN 3+ risk threshold for technologies with fewer than 5 years of follow-up data. This allows evidence-based guidance for surveillance intervals of 1 or 3 years for new technologies with limited longitudinal data.

How does re-classification of variants of unknown significance (VUS) impact the management of patients at risk for hereditary breast cancer?

BackgroundThe popularity of multigene testing increases the probability of identifying variants of uncertain significance (VUS). While accurate variant interpretation enables clinicians to be better informed of the genetic risk of their patients, currently, there is a lack of consensus management guidelines for clinicians on VUS.MethodsAmong the BRCA1 and BRCA2 mutations screening in 3,544 subjects, 236 unique variants (BRCA1: 86; BRCA2: 150) identified in 459 patients were being reviewed. These variants consist of 231 VUS and 5 likely benign variants at the initial classification.ResultsThe variants in 31.8% (146/459) patients were reclassified during the review, which involved 26 unique variants (11.0%). Also, 31 probands (6.8%) and their family members were offered high-risk surveillance and related management after these variants were reclassified to pathogenic or likely pathogenic. At the same time, 69 probands (15%) had their VUS downgraded to cancer risk equivalent to the general population level.ConclusionA review of archival variants from BRCA1 and BRCA2 genetic testing changed the management for 31.8% of the families due to increased or reduced risk. We encourage regular updates of variant databases, reference to normal population and collaboration between research laboratories on functional studies to define the clinical significances of VUS better.

Pregnancy maternal fetal outcomes among pregnancies complicated with atrioventricular block

BackgroundAtrioventricular block (AVB) during pregnancy is rare. Case study for pregnancy with AVB have been reported but a consensus guideline for peripartum management has not been established. This study aimed to investigate cardiac and obstetric complications and outcomes in our pregnant women with AVB and share our management experience.MethodsThis was a retrospective study. We reviewed a total of 74 pregnant women with AVB who delivered at our tertiary care center in the past 10 years. The patients were categorized into four groups according to the degree of block. The data were analyzed and compared among the four groups of patients.ResultsRegarding the cardiac complications, the cardiac function level showed significant difference among patient groups. The higher NYHA class were observed in patients with higher degree AVB. Pacemaker was placed before delivery in 32/33 patients with III° AVB, 8/25 patients with II° AVB, and 0/16 patient with I° AVB. Other types of arrhythmias except AVB were present in all groups of patients but more frequently observed in type I patients with II° AVB. No other heart abnormalities were observed among the patient groups. Obstetric complications were found in 21 women (28.4%), including premature labor, premature rupture of membranes (PROM), gestational diabetes mellitus (GDM), preeclampsia, etc. The incidence rate of fetal cardiac abnormalities was 6.58%. But no statistical difference was detected among four groups of patients for fetal and maternal complications and fetal cardiac abnormalities (P>0.05). Caesarean section was performed more in patients with high-degree AVB than in patients with low-degree AVB. No maternal or neonatal death in our cases.ConclusionsMost women with AVB could achieve successful pregnancy and delivery. Patients with II° AVB type II and III° AVB should be monitored vigilantly during pregnancy and post-partum. Temporary pacing before delivery appeared to be beneficial for women with III°AVB, and accurate diagnosis and care by a multidisciplinary team was recommended.

Barrett's esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies.

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.