National Clinical Practice Guidelines Research Articles

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus.

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia. This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/statements. A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence. This Saudi National Clinical Practice guidelines for SLE management provide evidence-based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Recommendations for the Clinical Development of Medicinal Products for Non-specific Influenza Chemoprophylaxis

INTRODUCTION. The evolution of the influenza virus has led to a gradual decrease in the effectiveness of current antivirals. Better methods of prevention, detection, control, and treatment of influenza are needed, including more effective vaccines and antivirals. At the moment, the Russian Federation and the Eurasian Economic Union lack documents regulating the conduct of clinical trials of medicinal products for influenza prevention and require that guidelines should be developed for the matter.AIM. The authors aimed to analyse the main regulatory approaches to preclinical and clinical development programmes for medicinal products for influenza prevention in the Russian Federation, the Eurasian Economic Union (EAEU), the European Union, and the United States of America.DISCUSSION. This review substantiates the importance of non-specific influenza chemoprophylaxis in reducing the risk of adverse outcomes of the disease. The authors analysed the main stages of preclinical development of medicinal products for influenza prevention and the potential contribution of preclinical studies to the planning of clinical trials. When developing preclinical and clinical programmes for medicinal products for influenza prevention, it is necessary, first of all, to take into account the requirements of the national good clinical practice guidelines and the EAEU guidelines for clinical trials in general. This article pays particular attention to the clinical trial designs used internationally, the possible options for their implementation, the characteristics of study populations, the formation of study groups, and the selection of primary and secondary endpoints.CONCLUSIONS. The article proposes approaches to planning and conducting clinical trials of medicinal products for the prevention of influenza, taking into account the specifics of legal norms and clinical traditions of Russian practice. These recommendations will ensure high-quality data on the effectiveness and safety of investigational medicinal products and accelerate the introduction of new effective medicinal products for influenza prevention into medical practice.

Live Biotherapeutic Products for the Prevention of Recurrent Clostridioides difficile Infection.

To review the efficacy, safety, and role of live biotherapeutic products (LBPs) in the prevention of recurrent Clostridioides difficile infection (rCDI). A literature search was performed using PubMed and Google Scholar (through February 2024) with search terms RBX2660, SER-109, and fecal microbiota. Other resources included abstracts presented at recent conferences, national clinical practice guidelines, and manufacturers' websites. All relevant studies, trial updates, conference abstracts, and guidelines in the English language were included. Two LBPs were recently approved by the Food and Drug Administration for the prevention of recurrence in adults following antibiotic treatment for rCDI. Fecal microbiota, live-jslm is administered rectally as a retention enema, whereas fecal microbiota spores, live-brpk is given orally after bowel preparation. Several phase 2 and phase 3 clinical trials have established the safety and efficacy of these LBPs in reducing rates of rCDI compared with placebo. Patients with severe immunosuppression and those with inflammatory bowel disease were largely excluded from these trials. Live biotherapeutic products offer a similar mechanism to conventional fecal microbiota transplant (FMT) in preventing rCDI through microbiota restoration. The primary advantages of LBPs over FMT are their standardized composition and donor stool screening processes for transmissible pathogens. Bezlotoxumab is also available for the prevention of Clostridioides difficile infection; however, there are no clinical data available to compare the efficacy of LBPs with bezlotoxumab, and the benefit of simultaneous use of these preventative therapies is unclear. Live biotherapeutic products provide a safe and effective option for the prevention of rCDI and represent an improvement over conventional FMT. Additional studies are needed to further determine their place in therapy relative to bezlotoxumab and in the setting of immunosuppression and inflammatory bowel disease.

Towards national paediatric clinical practice guidelines.

Towards national paediatric clinical practice guidelines.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer.

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer. This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG. This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations. This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

A qualitative analysis of algorithm-based decision support usability testing for symptom management across the trajectory of cancer care: one size does not fit all

BackgroundAdults with cancer experience symptoms that change across the disease trajectory. Due to the distress and cost associated with uncontrolled symptoms, improving symptom management is an important component of quality cancer care. Clinical decision support (CDS) is a promising strategy to integrate clinical practice guideline (CPG)-based symptom management recommendations at the point of care.MethodsThe objectives of this project were to develop and evaluate the usability of two symptom management algorithms (constipation and fatigue) across the trajectory of cancer care in patients with active disease treated in comprehensive or community cancer care settings to surveillance of cancer survivors in primary care practices. A modified ADAPTE process was used to develop algorithms based on national CPGs. Usability testing involved semi-structured interviews with clinicians from varied care settings, including comprehensive and community cancer centers, and primary care. The transcripts were analyzed with MAXQDA using Braun and Clarke’s thematic analysis method. A cross tabs analysis was also performed to assess the prevalence of themes and subthemes by cancer care setting.ResultsA total of 17 clinicians (physicians, nurse practitioners, and physician assistants) were interviewed for usability testing. Three main themes emerged: (1) Algorithms as useful, (2) Symptom management differences, and (3) Different target end-users. The cross-tabs analysis demonstrated differences among care trajectories and settings that originated in the Symptom management differences theme. The sub-themes of “Differences between diseases” and “Differences between care trajectories” originated from participants working in a comprehensive cancer center, which tends to be disease-specific locations for patients on active treatment. Meanwhile, participants from primary care identified the sub-theme of “Differences in settings,” indicating that symptom management strategies are care setting specific.ConclusionsWhile CDS can help promote evidence-based symptom management, systems providing care recommendations need to be specifically developed to fit patient characteristics and clinical context. Findings suggest that one set of algorithms will not be applicable throughout the entire cancer trajectory. Unique CDS for symptom management will be needed for patients who are cancer survivors being followed in primary care settings.

Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical...

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Receipt of Guideline-Concordant Care Is Associated With Improved Survival in Patients With Osteosarcoma in California: A Population-Based Analysis.

To examine the relationship between guideline-concordant care (GCC) on the basis of national clinical practice guidelines and survival in children (0-14 years), adolescents and young adults (AYAs, 15-39 years), and adults (40 years and older) with osteosarcoma, and to identify sociodemographic and clinical factors associated with receipt of GCC and survival. We used data from the California Cancer Registry (CCR) on patients diagnosed with osteosarcoma during 2004-2019, with detailed treatment information extracted from the CCR text fields, including chemotherapy regimens. Multivariable logistic and Cox proportional hazard regression were used for statistical analyses. Of 1,716 patients, only 47% received GCC, with variation by age at diagnosis: 67% of children, 43% of AYAs, and 30% of adults. In multivariable models, patients who received part or all care (v none) at specialized cancer centers were more likely to receive GCC. AYAs and adults were less likely to receive GCC than children (odds ratio [OR], 0.38 [95% CI, 0.30 to 0.50] and OR, 0.40 [95% CI, 0.28 to 0.56], respectively). In a model excluding adults, patients treated by pediatric (v medical) oncologists were more likely to receive GCC (OR, 3.44 [95% CI, 2.40 to 4.94]). Patients with metastatic osteosarcoma at diagnosis who did not receive GCC had a greater hazard of death (hazard ratio [HR], 2.02 [95% CI, 1.55 to 2.63]) but no statistical differences were found in those diagnosed at earlier stages (HR, 1.15 [95% CI, 0.92 to 1.43]). GCC was associated with improved survival in patients with metastatic osteosarcoma in California. However, we found disparities in the delivery of GCC, highlighting the need for target interventions to improve delivery of GCC in this patient population.

Newborn and child health national and provincial clinical practice guidelines in South Africa, Nigeria and Malawi: a scoping review

BackgroundLow and middle-income countries remain disproportionately affected by high rates of child mortality. Clinical practice guidelines are essential clinical tools supporting implementation of effective, safe, and cost-effective healthcare. High-quality evidence-based guidelines play a key role in improving clinical management to impact child mortality. We aimed to identify and assess the quality of guidelines for newborn and child health published in South Africa, Nigeria and Malawi in the last 5 years (2017–2022).MethodsWe searched relevant websites (June–July 2022), for publicly available national and subnational de novo or adapted guidelines, addressing newborn and child health in the three countries. Pairs of reviewers independently extracted information from eligible guidelines (scope, topic, target population and users, responsible developers, stakeholder consultation process, adaptation description, assessment of evidence certainty). We appraised guideline quality using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument.ResultsWe identified 40-guidelines from the three countries. Of these, 8/40 reported being adopted from a parent guideline. More guidelines (n = 19) provided guidance on communicable diseases than on non-communicable diseases (n = 8). Guidelines were most often developed by national health ministries (n = 30) and professional societies (n = 14). Eighteen guidelines reported on stakeholder consultation; with Nigeria (10/11) and Malawi (3/6) faring better than South Africa (5/23) in reporting this activity. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used in 1/7 guidelines that reported assessing certainty of evidence. Overall guidelines scored well on two AGREE II domains: scope and purpose median (IQR) score 68% (IQR 47–83), and clarity of presentation 81% (67–94). Domains critical for ensuring credible guidance scored below 20%: rigour of development 11% (4–32) and editorial independence 6% (0–27).ConclusionNational ministries and professional societies drive guideline activities in Malawi, Nigeria and South Arica. However, the methods and reporting do not adhere to global standards. We found low AGREE II scores for rigour of guideline development and editorial independence and limited use of GRADE or adaptation methods. This undermines the credibility of available guidelines to support evidence-informed care. Our findings highlight the importance of ongoing efforts to strengthen partnerships, capacity, and support for guideline development.

Concordance between essential medicines lists and diabetes guidelines in Latin America and the CaribbeanConcordância entre as listas de medicamentos essenciais e diretrizes para diabetes na América Latina e no Caribe

Conduct an analysis to determine the existence and updating of national essential medicines lists (EMLs) and clinical practice guidelines (CPGs) for the treatment of diabetes in Latin America and the Caribbean (LAC); and compare the medicines included in each country's list and guidelines both with each other and with those of the World Health Organization (WHO). Cross-sectional study. EMLs and CPGs for diabetes were found on the websites of the Pan American Health Organization and national health authorities. Medicines were noted and analyzed according to pharmacological group, based on the fourth level of nomenclature of the Anatomical Therapeutic Chemical (ATC) classification system. F1 scoring was used to assess the proximity of EMLs to the WHO Model List of Essential Medicines (MLEM). Of the total number of countries, 87.2% have EMLs, and 91% have CPGs (78% and 45% updated in the last five years, respectively). Compared to the six hypoglycemic groups of the MLEM, the EMLs had a median (range) of 6 (4-13) and an F1 score of 0.80; This indicates proper alignment. CPGs had a median (range) of 12 (1-12) hypoglycemic drugs compared to eight in the WHO guidelines. CPGs had a median of 15 more drugs than their respective EMLs. While most LAC countries have EMLs and CPGs for diabetes, the lack of concordance among them limits their effectiveness. It is necessary to align the processes and criteria for the development of these two tools for policymaking on medicines.

N32 Implementation of chromoendoscopy in colorectal cancer screening in patients with Inflammatory Bowel Disease

Abstract Background Patients with inflammatory bowel disease (IBD) have a higher risk of colorectal cancer (CRC), so we must implement the best available endoscopic technique to detect it early, decreasing the risk of CRC and death. There is low adherence to CRC screening by chromoendoscopy with dye in patients with IBD, despite the fact that national and international clinical practice guidelines consider this technique of choice based on the available evidence. Description Of The Initiative The standardization of a screening procedure, based on the evidence of endoscopy, allows any member of the team, doctor or nurse, to detect the need for the indication, improving screening in terms of follow-up interval and technique. Likewise, the inflammatory nurse will have to know the technique to be able to inform the patient and improve their adherence, preparation and resolve doubts. The main aim is early detection of dysplasia and CRC. The side aims are: ▪ To improve the implementation of chromoendoscopy as a technique for CRC screening. ▪ Improve patient adherence to colonoscopy. Methods The development of an endoscopic follow-up procedure according to risk factors in patients with ulcerative colitis and colonic Crohn's disease, in which chromoendoscopy is the technique of choice. The technique in our center is with 0.4% carmine indigo diffusion with catheter-diffuser, but it is possible to adapt other alternatives according to availability. The procedure establishes the follow-up interval at 1, 3 or 5 years depending on the low, medium or high risk, respectively, depending on the activity, extent and duration of the disease, presence of stenosis and pseudopolyps, primary sclerosing cholangitis and/or family history of CRC. Results In our center, 100% of screenings are performed by chromoendoscopy with dye, by a single expert endoscopist, scheduled with a longer examination time than a conventional colonoscopy and with optimization of bowel preparation. Conclusion CRC screening of patients with IBD should preferably be performed with chromoendoscopy with dye, establishing follow-up intervals depending on known risk factors, both clinical, endoscopic and histological, and this indication should be standardized in a procedure that is known to all members of the team.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims.

The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening. Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ2 analysis are reported. Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments. Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Coronary artery calcium (CAC) score for cardiovascular risk stratification in a Thai clinical cohort: A comparison of absolute scores and age-sex-specific percentiles

PurposesCoronary artery calcium (CAC) score provides a quantification of atherosclerotic plaque within the coronary arteries. This study aimed to examine the prevalence and CAC score distribution and to evaluate the association of each CAC score classifications with major adverse cardiovascular events (MACE) in a Thai clinical cohort. MethodsThis study was a retrospective observational cohort. We included patients aged above 35 years who underwent CAC score testing. The absolute and age-sex specific percentile classifications were categorized as 0, 1 to 10, 11 to 100, 101 to 400, and >400 and 0, <75th, 75th – 90th, and >90th, respectively. The endpoint was MACE, including cardiovascular death, myocardial infarction, heart failure hospitalization, coronary artery revascularization procedure, and stroke. Multivariable Cox regression was used to estimate the hazard ratios. The discriminative performance between classifications were compared using Harrell's C-statistics. The agreement was assessed via Cohen's Kappa. ResultsThis study included 440 patients, with approximately 70% of Thai patients exhibiting a CAC score. CAC score distributed higher in male than female and increased with age. Both CAC score classification demonstrated the acceptable predictive performance. However, fair agreement was observed between classifications (Cohen's kappa 0.51, 95%CI 0.42–0.59). Within the absolute classification, a higher CAC score was associated with increased hazard ratios for MACE across stratified age-sex-specific percentile levels. In contrast, the hazard ratios for MACE did not consistently rise with higher age-sex-specific percentile CAC score when stratified by absolute CAC score levels. ConclusionsBoth absolute and age-sex-specific percentile CAC score demonstrated acceptable performance in predicting MACE. However, the absolute CAC score classification may be more suitable for risk stratification within the Thai clinical cohort. Our findings offer supportive information that could inform future recommendations for CAC score testing criteria within national clinical practice guidelines.

Palliative care for children: methodology for the development of a national clinical practice guideline

BackgroundProvision of paediatric palliative care for children with life-threatening or life-limiting conditions and their families is often complex. Guidelines can support professionals to deliver high quality care. Stakeholders expressed the need to update the first Dutch paediatric palliative care guideline with new scientific literature and new topics. This paper provides an overview of the methodology that is used for the revision of the Dutch paediatric palliative care guideline and a brief presentation of the identified evidence.MethodsThe revised paediatric palliative care guideline was developed with a multidisciplinary guideline panel of 72 experts in paediatric palliative care and nine (bereaved) parents of children with life-threatening or life-limiting conditions. The guideline covered multiple topics related to (refractory) symptom treatment, advance care planning and shared-decision making, organisation of care, psychosocial care, and loss and bereavement. We established six main working groups that formulated 38 clinical questions for which we identified evidence by updating two existing systematic literature searches. The GRADE (CERQual) methodology was used for appraisal of evidence. Furthermore, we searched for additional literature such as existing guidelines and textbooks to deal with lack of evidence.ResultsThe two systematic literature searches yielded a total of 29 RCTs or systematic reviews of RCTs on paediatric palliative care interventions and 22 qualitative studies on barriers and facilitators of advance care planning and shared decision-making. We identified evidence for 14 out of 38 clinical questions. Furthermore, we were able to select additional literature (29 guidelines, two textbooks, and 10 systematic reviews) to deal with lack of evidence.ConclusionsThe revised Dutch paediatric palliative care guideline addresses many topics. However, there is limited evidence to base recommendations upon. Our methodology will combine the existing evidence in scientific literature, additional literature, expert knowledge, and perspectives of patients and their families to provide recommendations.

673. Sniffing Out Adherence: Evaluation of a Clostridioides difficile guideline at a Tertiary Academic Medical Center

Abstract Background Tufts Medical Center’s (TMC) Antimicrobial Stewardship Team (AMT) in collaboration with gastroenterology (GI) developed an institutional treatment algorithm to guide appropriate inpatient management of Clostridioides difficile infection (CDI). The CD treatment algorithm was revised in April 2022 to reflect updated national clinical practice guidelines and disseminated to TMC providers. Our study aimed to assess provider compliance to TMC’s CD treatment algorithm. Methods A retrospective study of adult patients hospitalized from April 15, 2022 to October 31, 2022 and tested for CD was conducted. We collected patient demographics, white blood cell count, serum creatinine (SC), length of stay, CD treatment, Infectious Diseases (ID) &amp; GI consult, occurence of severe CDI (defined as white blood cell &amp;gt; 15 K/uL or SC &amp;gt; 1.5 mg/dL), occurrence of recurrent CDI, and immunocompromised status (defined by having had organ or bone marrow transplant, receiving immunomodulatory therapy or chronic steroids). A 2-step Clostridioides difficile (CD) testing algorithm was used. For CD toxin A/B &amp; glutamate dehydrogenase antigen (GDH) indeterminate results, reflex to nucleic amplification test (NAAT) was performed only with AMT approval. Results A total of 111 inpatients had CD toxin/GDH stool testing; 70 (63%) positive and 41 (37%) indeterminate. Of patients who had an indeterminate CD toxin/GDH, none had subsequent CD NAAT testing, and none receive CDI treatment. Of the others, 81 (73%), 23 (21%), and 7 (6%) were diagnosed with non-severe, severe, and fulminant CDI, respectively. The overall adherence to the institutional CD treatment algorithm was 58% (figure 1). More patients were appropriately treated with oral vancomycin (11, 65%) compared to those who were appropriately treated with fidaxomicin (9, 24%). Guidance adherence was (3) 38% among patients who had one or more recurrent episodes of CD, and none received suggested ID or GI consultation for additional CDI treatment consideration. Conclusion Adherence to institutional CD treatment algorithm was low. This study highlights opportunities to improve prescription of first line CDI therapy, especially among patients who are at higher risk for recurrence. Disclosures Maureen Campion, PharmD, BCIDP, Shinoigi: Speaker

Functional Neurological Disorder in Saudi Arabia: An Update.

Functional neurological disorder (FND) is characterized by neurological symptoms that lack congruence with traditional neurological diagnoses. Historically viewed through a Freudian psychoanalytic lens, FND has been conceptualized as a purely psychogenic disorder. However, the contemporary biopsychosocial perspective on FND emphasizes contributions of cognitive and neural circuit dysfunctionand the disabling and involuntary nature of the illness. In Saudi Arabia, evidence suggests the prevalence of FND is significant. However, clinical programs and research focused on FND have been lacking. Studies from the region indicate that practitioners may have outdated views of FND. To address this, this narrative review provides an updated perspective on FND that is relevant to Saudi Arabia and the region. It delves into the evolving perception of FND, its underlying pathophysiology, risk factors, clinical presentations, and recent diagnostic and management advances. Unique features of FND in Saudi Arabia may include a significant role for family disputes as a risk factor, prevalent supernatural perceptions of FND, high prevalence of somatization, and cognitive dysfunction, and a potential favorable prognosis. The article concludes by providing the following recommendations related to FND in Saudi Arabia and the region: i) building educational programs to update clinicians about contemporary biopsychosocial perspectives on FND; ii) emphasizing a positive diagnostic approach based on clinical findings in FND; iii) instituting multidisciplinary programs to care for FND patients; iv) supporting systematic research efforts to explore culture-specific FND risk factors, patient outcome measures, and attitudes toward the disorder; v) developing national FND clinical practice guidelines; and vi) launching awareness campaigns to reduce FND stigma.

Assessment of knowledge, attitude, and practice of primary healthcare physicians in Qatar towards hypertension management: An online cross-sectional study.

Primary health care is integral to diagnosing and managing hypertension. This study aimed to assess the knowledge, attitude, practice, priority, and confidence of primary care physicians in Qatar toward hypertension diagnosis and management, and to measure the determinants of good knowledge, desirable attitudes, and desirable practices. We conducted a cross-sectional web-based survey using a modified version of the World Hypertension League Questionnaire during the period from August 30th to October 23rd, 2020. All primary care physicians working in any of Qatar's 27 publicly run primary healthcare centers were invited to participate in the survey. Out of the 450 primary care physicians working at that time, 197 completed the study questionnaire with a response rate of 43.8%. Most respondents stated that they followed local or international treatment guidelines for hypertension management (96.4%). Primary care physicians were highly confident and prioritized hypertension management. The overall desirable practice score was 73.8%, with the highest score (95.4%) for assessing adherence to antihypertensive medications, whereas the lowest desirable practice score was 33.5% for counseling on home blood pressure monitoring. Fifty-one-point eight percentage and 62.4% correctly identified 140 mm Hg and 90 mm Hg as the systolic and diastolic blood pressure threshold for diagnosing hypertension in most patients. The lowest knowledge scores were for hypertension epidemiology in Qatar and recommended dietary modification for hypertensive patients. Respondents had positive attitudes toward task sharing with nonphysician healthcare workers for most items (58.9%-78.2%), except for drug prescriptions (30.5%). Primary care physicians in Qatar had positive attitudes, with high overall confidence and conviction (priority) scores toward hypertension. However, their knowledge scores and certain practices were suboptimal. Healthcare policymakers in Qatar should raise primary care physicians awareness of the current burden of untreated hypertension in the country by organizing targeted educational programs and emphasizing the importance of following national clinical practice guidelines in the diagnosis and management of hypertension.

The Venous Thrombectomy Armamentarium: An Expanding World.

Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient's anatomy, lesion, and history.

A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth.

The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4 ) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1-24 h prior to delivery before gestational age 32+0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation. Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+0-31+6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded. A total of 388 women were eligible and 79% received treatment with MgSO4 . Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h). There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.