Panel Of Clinicians Research Articles

A147 COMBINING INFLIXIMAB TROUGH LEVELS AND FECAL CALPROTECTIN LEVELS WITH CLINICAL DATA HAS THE POTENTIAL TO GUIDE CLINICAL DECISION-MAKING IN IMPROVING OUTCOMES FOR INFLAMMATORY BOWEL DISEASE PATIENTS ON MAINTENANCE INFLIXIMAB.

AbstractBackgroundInfliximab (IFX) induces and maintains remission in Crohn’s Disease (CD) and Ulcerative Colitis (UC). Secondary loss of response occurs in up to 45% of CD and 60% of UC patients on maintenance IFX. Studies are inconclusive on ideal IFX trough levels (ITLs) to prevent loss of response; recommendations range from “detectable” up to 10μg/mL. Patients with adequate ITLs still lose response, suggesting they still have gastrointestinal (GI) inflammation. Fecal Calprotectin (FCP), a marker of neutrophilic infiltration into the GI tract, when elevated predicts loss of response to maintenance IFX (sensitivity 0.80, specificity 0.82). We previously showed clinicians would alter decisions based on ITLs and FCP levels. There are no studies on using ITLs and FCP levels in conjunction with clinical presentation.AimsTo determine if 6 month outcomes in IBD outpatients on IFX maintenance could be improved if clinicians had knowledge of both ITLs and FCP levels in addition to clinical data.MethodsThis was a pilot, retrospective case series of adult IBD outpatients on maintenance IFX, who prior to having levels drawn were in clinical remission. Actual clinical decisions were based on clinical presentation and standard labs. All subjects had blood ITLs drawn. A subset (Group 2) provided stools for FCP levels. An expert clinician panel made hypothetical clinical decisions with ITLs and FCP levels. Interval (between ITL and 6-months) and final 6-month outcomes were recorded. Comparisons were made between: actual clinical decisions and what ITLs should prompt (Group 1); and actual clinical decisions, what ITLs and FCP levels should prompt, and hypothetical clinical decisions (Group 2). Statistical analyses included: medians with interquartile ranges (IQRs); proportions; percentages; chi-squared and non-parametric analyses.Results Table 1 captures baseline demographics. There were no statistically significant differences in demographics between the two groups. Table 2 highlights patients in (a) Group 1 and (b) Group 2 in whom ITL and/or FCP levels could have impacted clinical decision making. Of note, 2 out of the 6 patients (Group 2) had “adequate” ITLs but elevated FCP. Table 2 further summarizes what could have been done to prevent the clinical outcomes that occurred without these levels.ConclusionsWhile previous studies have explored the use of ITLs and FCP levels in isolation, the results of this study demonstrate that knowledge of ITLs and FCP levels together, in addition to the patient’s clinical presentation, can aid clinicians to optimize management and improve outcomes of IBD outpatients on IFX maintenance.Funding AgenciesNoneN/A

Poster Abstracts

Background and Objective: To obtain consensus on appropriate modifications of adult lower limb neurological testing of strength, tactile sensitivity and reflexes for paediatric clients. Study Design: A modified Delphi technique with two electronic survey rounds. Methods: An expert panel of experienced paediatric neurological physiotherapy clinicians and academics (n=34) were invited to complete surveys. Survey 1 consisted of open‐ended questions and statements generated by review of the literature. Experts were required to rate their level of agreement with statements using a 1–6 Likert scale (strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree). Survey 2 consisted of statements generated from thematic analysis of responses to open‐ended questions and statements that did not reach consensus in Survey 1. A‐priori criteria for item consensus was set at 65% strongly agree, agree, or somewhat agree or 65% strongly disagree, disagree, or somewhat disagree. The median and interquartile range of Likert scores was calculated to estimate perceived importance for each item. Results: Twenty‐four experts from nine countries completed both surveys. Consensus was reached on 92% of total items (n=292/316). Consensus agreement was reached on 92% of items (n=34/39) relating to modifications of adult neurological tests for paediatric clients. Consensus was also reached on 96% of items (n=27/28) relating to tests required for interpretation of results, 88% of items (n=15/17) on equipment use, and 61% of items (n=11/18) relating to measurement scales utilised to grade impairments. Experts perceived with strong agreement (>85%) and strong importance (strongly agree) that paediatric tests should be developmentally appropriate (96%, IQR: 5,6), include functional observation (96%, IQR: 5,6) and incorporate fun and play (92%, IQR: 5,6) to maintain a child's motivation (100%, IQR: 6,6). Experts also perceived with strong agreement and importance that instructions could be modified by using a child's own words (96%, IQR: 5,6) or non‐verbal communication (96%, IQR: 4.75,6) and that children should be familiarised with test equipment (100%, IQR: 5,6) and have tests demonstrated (92–96%, IQR: 5,6) prior to testing. Conclusions: This is the first study to report on modifications of adult lower limb neurological tests for paediatric clients. Expert consensus was reached regarding several modifications, however there was variability in the type of modifications which may impact the interpretation and reporting of results. The appropriateness of suggested modifications of adult tests will need to be verified through clinimetric analysis of these properties in paediatric clients of different ages and diagnoses.

Clinical interpretation of pathogenic ATM and CHEK2 variants on multigene panel tests: navigating moderate risk.

Comprehensive genomic cancer risk assessment (GCRA) helps patients, family members, and providers make informed choices about cancer screening, surgical and chemotherapeutic risk reduction, and genetically targeted cancer therapies. The increasing availability of multigene panel tests for clinical applications allows testing of well-defined high-risk genes, as well as moderate-risk genes, for which the penetrance and spectrum of cancer risk are less well characterized. Moderate-risk genes are defined as genes that, when altered by a pathogenic variant, confer a 2 to fivefold relative risk of cancer. Two such genes included on many comprehensive cancer panels are the DNA repair genes ATM and CHEK2, best known for moderately increased risk of breast cancer development. However, the impact of screening and preventative interventions and spectrum of cancer risk beyond breast cancer associated with ATM and/or CHEK2 variants remain less well characterized. We convened a large, multidisciplinary, cross-sectional panel of GCRA clinicians to review challenging, peer-submitted cases of patients identified with ATM or CHEK2 variants. This paper summarizes the inter-professional case discussion and recommendations generated during the session, the level of concordance with respect to recommendations between the academic and community clinician participants for each case, and potential barriers to implementing recommended care in various practice settings.

Developing “Goals of Care” for Your Organization: Strategic Planning for the Palliative Care Professional (TH335)

•Describe different ways to develop a business, operations, and personnel strategy for medium and long term planning.•Understand avenues to evaluate internal and immediately-available resources, assets, and strengths and then critically appraise external threats and align future actions in response to organizational priorities.•Collate input from experts and audience members regarding real-life practical tips for timing and execution of strategic planning. In an evolving healthcare environment, including rapid changes to evaluation and reimbursement of care, palliative care clinicians need a robust strategy to sustain their competitive advantage. As clinical programs grow into outpatient practices and venture into community-based settings, they often set out to complete a lengthy and intensive retreat to define a mission and vision. Sometimes they also perform a SWOT analysis, but upon completion, oftentimes clinicians and administrators go back to an uncoordinated, misaligned clinical delivery apparatus. Frankly, these efforts are not fruitful, either because they lack the rigor in approach or use methods not tailored to the needs of palliative care organizations. Using an interdisciplinary panel of clinicians with backgrounds in palliative care program development, palliative care longitudinal growth, and corporate world business strategy, we will discuss several topics critical to strategic planning. We will cover topics being taught in business schools today, applying these concepts to our palliative care clinical world. Topics covered will include eliminating fluff, aligning with the overall organization's strategy for healthcare, developing strategy using the 5-diamond approach, and differentiating strategic positioning versus operational efficiency. Further, we will provide attendees real-world palliative care business cases, highlighting important tasks “to implement on Monday” such as: understanding external threats, appreciating internal resources, and using the 9-box matrix for prioritizing efforts. Our goal is to demystify strategic planning, making it an everyday skill for palliative care professionals to participate in, and use regularly in their operational toolbox.

Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care.

Background:Underpinning standards for developing comprehensive care in hospital is the need to identify, early in the admission process, functional and psychosocial issues which affect patient outcomes. Despite the value of comprehensive assessment of patients on admission, the process is often sub-optimal due to a lack of standardized assessment practices. This project aimed to develop a concise, integrated assessment for patients admitted to acute care and test its psychometric properties.Methods:Two international expert panels of clinicians and health scientists collaborated to establish design parameters. Using clinical observations and a variety of derivative applications sourced from the interRAI research collaborative repository, the panels constructed a draft instrument to examine feasibility, resource requirements, and inter-rater reliability. Field testing was conducted in Australia and Canada. Next, the system was revised to its final form, the interRAI Acute Care, after feedback and review from international interRAI members.Results:Constructed using 56 items, the interRAI Acute Care required a median of 15 minutes to complete. Inter-rater reliability tested on 130 paired assessments was substantial to almost perfect for 78% of the clinical items and moderate for the remaining 22% of items. A subset of 30 items from the admission assessment comprised the discharge assessment.Discussion:The interRAI Acute Care has been shown to be an efficient nursing assessment instrument with good psychometric properties. Implementation in a digital environment will enable documentation and care planning to comply with standards for quality of care in the general adult hospital population.

Development of quality indicators for hip and knee arthroplasty rehabilitation.

To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets. Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three 'across-continuum' QIs were rated appropriate for both procedures. This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.

Preoperative Stratification of Transsphenoidal Pituitary Surgery Patients Based on Surgical Urgency.

Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment. To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates. An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways. We identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary adenomas, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%. We developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients.

Discussing Benefits and Risks of Tracheostomy: What Physicians Actually Say.

When contemplating tracheostomy placement in a pediatric patient, a family-physician conference is often the setting for the disclosure of risks and benefits of the procedure. Our objective was to compare benefits and risks of tracheostomy presented during family-physician conferences to an expert panel's recommendations for what should be presented. We conducted a retrospective review of 19 transcripts of audio-recorded family-physician conferences regarding tracheostomy placement in children. A multicenter, multidisciplinary expert panel of clinicians was surveyed to generate a list of recommended benefits and risks for comparison. Primary analysis of statements by clinicians was qualitative. Single-center PICU of a tertiary medical center. Family members who participated in family-physician conferences regarding tracheostomy placement for a critically ill child from April 2012 to August 2014. We identified 300 physician statements describing benefits and risks of tracheostomy. Physicians were more likely to discuss benefits than risks (72% vs 28%). Three broad categories of benefits were identified: 1) tracheostomy would limit the impact of being in the PICU (46%); 2) perceived obstacles of tracheostomy can be overcome (34%); and 3) tracheostomy optimizes respiratory health (20%). Risks fell into two categories: tracheostomy involves a big commitment (71%), and it has complications (29%). The expert panel's recommendations were similar to risks and benefits discussed during family conferences; however, they suggested physicians present an equal balance of discussion of risks and benefits. When discussing tracheostomy placement, physicians emphasized benefits that are shared by physicians and families while minimizing the risks. The expert panel recommended a balanced approach by equally weighing risks and benefits. To facilitate educated decision making, physicians should present a more extensive range of risks and benefits to families making this critical decision.

The histopathological classification, diagnosis and differential diagnosis of mucinous appendiceal neoplasms, appendiceal adenocarcinomas and pseudomyxoma peritonei.

The vermiform appendix is the primary site of several distinctive benign and malignant neoplasms. Some can produce the clinical syndrome of pseudomyxoma peritonei (PMP). A consensus on their terminology was reached by an international panel of pathologists and clinicians working under the auspices of the Peritoneal Surface Oncology Group International (PSOGI), and this review discusses the application of the PSOGI classification to routine reporting. We discuss diagnosis and differential diagnosis together with implications for patient management, covering low-grade appendiceal mucinous neoplasms, high-grade appendiceal mucinous neoplasms, serrated polyps, adenomas and adenocarcinomas. We do not cover goblet cell tumours or neuroendocrine neoplasms in this paper.

Measuring Pain Catastrophizing and Pain-Related Self-Efficacy: Expert Panels, Focus Groups, and Cognitive Interviews.

Pain-related self-efficacy and pain catastrophizing are important psychosocial determinants of pain and can be therapeutic targets for chronic pain management. Advances in psychometric science have made shorter or dynamically administered instruments possible. The aim of this study was to generate and test candidate items for two new patient-reported outcome measures of pain-related self-efficacy and pain catastrophizing. An expert panel of pain clinicians and researchers was convened to establish construct definitions of pain-related self-efficacy and pain catastrophizing and guide item development. Two patient advisors provided guidance throughout the project. Nineteen people with chronic pain participated in focus groups about their perspectives and experiences related to pain-related self-efficacy and pain catastrophizing. Twenty-two people with chronic pain participated in cognitive interviews to test proposed candidate items. Saturation was reached after three focus groups with no new subdomains identified by participants in the third focus group. Following cognitive interviews, five of the 48 initial pain-related self-efficacy candidate items were dropped and seven required substantial revision resulting in 43 pain-related self-efficacy candidate items. After two rounds of cognitive interviews, ten items were eliminated and ten substantially revised, resulting in a set of 30 from the initial 43 pain catastrophizing candidate items. This article summarizes results of the qualitative phase of the development of new measures of pain-related self-efficacy and pain catastrophizing. Candidate items will be field tested with a large sample of people with chronic pain and the data will be used to calibrate items to an item response theory model. Resulting item banks and short forms will be made publicly available to researchers and clinicians.

Canadian Treatment Guidelines on Psychosocial Treatment of Schizophrenia in Children and Youth.

A panel of experts, including researchers, clinicians and people with lived experience, was brought together to develop the new Canadian schizophrenia guidelines for the psychosocial treatment of children and youth with schizophrenia or psychotic disorders. The ADAPTE process, which relies on adapting existing high-quality guidelines, was used. Existing guidelines for children and youth (mostly from the National Institute for Health and Care Excellence [NICE]), as well as CPA adult guidelines, were reviewed and discussed in terms of their adaptability to the Canadian context and their level of recommendation for children and youth. New treatments were also considered when recent meta-analyses suggested their usefulness. The children and youth psychosocial guidelines include many cross-sectional recommendations in terms of clinical and interpersonal skills needed to work with this clientele, setting and collaboration issues and needed adaptations for specific subpopulations. In terms of specific treatments, the treatments most strongly recommended are family intervention and cognitive behavior therapy. Also recommended, although with different degrees of support, are supported employment/supported education programs, patient education, cognitive remediation, and social skills training. Novel and upcoming psychosocial treatments are also briefly discussed. These novel Canadian guidelines for the psychosocial treatment of children and youth with schizophrenia or psychotic disorders report evidence-based treatments as well as important considerations for providers who work with this clientele. More studies with children and youth with schizophrenia and psychotic disorders are warranted. If followed, these guidelines should facilitate the recovery of children and youth with schizophrenia or psychotic disorders as well as the recovery of their families.

Is intraindividual reaction time variability an independent cognitive predictor of mortality in old age? Findings from the Sydney Memory and Ageing Study.

Intraindividual variability of reaction time (IIVRT), a proposed cognitive marker of neurobiological disturbance, increases in old age, and has been associated with dementia and mortality. The extent to which IIVRT is an independent predictor of mortality, however, is unclear. This study investigated the association of IIVRT and all-cause mortality while accounting for cognitive level, incident dementia and biomedical risk factors in 861 participants aged 70–90 from the Sydney Memory and Ageing Study. Participants completed two computerised reaction time (RT) tasks (76 trials in total) at baseline, and comprehensive medical and neuropsychological assessments every 2 years. Composite RT measures were derived from the two tasks—the mean RT and the IIVRT measure computed from the intraindividual standard deviation of the RTs (with age and time-on-task effects partialled out). Consensus dementia diagnoses were made by an expert panel of clinicians using clinical criteria, and mortality data were obtained from a state registry. Cox proportional hazards models estimated the association of IIVRT and mean RT with survival time over 8 years during which 191 (22.2%) participants died. Greater IIVRT but not mean RT significantly predicted survival time after adjusting for age, sex, global cognition score, cardiovascular risk index and apolipoprotein ɛ4 status. After excluding incident dementia cases, the association of IIVRT with mortality changed very little. Our findings suggest that greater IIVRT uniquely predicts shorter time to death and that lower global cognition and prodromal dementia in older individuals do not explain this relationship.

Transdiagnostic Dimensional Assessment of Psychopathology in Later Life

The purpose of this review is to present a transdiagnostic dimensional approach to evidence-based assessment designed to facilitate applications of neuroscientific advances to phenotypic psychopathology in later life. Standardized assessment forms were developed to obtain collateral- and self-ratings of a broad spectrum of behavioral, emotional, social, and thought problems, as well as strengths. Factor analyses of ratings of American elders yielded seven syndromes, while judgments by international panels of expert clinicians yielded six DSM-oriented scales. Gender-specific norms for ages 60–75 and >75 years enable users to view individuals’ scale scores in relation to scores for population samples of peers. Cross-informant comparisons are designed to reveal important discrepancies and consistencies between collateral- and self-ratings. Significant associations are found between the dimensional measures and psychiatric disorders. Multicultural research supports the generalizability of the statistically derived syndromes. Indigenous researchers are obtaining data for testing syndromes and comparing problems and strengths across many societies. Standardized transdiagnostic dimensional assessments can be used in multiple societies to construct multicultural norms based on collateral- and self-ratings and can foster international collaboration to advance clinical services, neuroscientific research, and training.

171 - Heart Failure Diagnostics Sensor Measurements Change Prior to Heart Failure Decompensation Events

Background: The Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients study (MultiSENSE) followed 900 heart failure (HF) patients with a modified CRT defibrillator for up to 1 year. HF decompensation events (HFE) were collected and adjudicated by an independent panel of clinicians. Data from multiple HF diagnostic sensors were continuously measured and saved by the modified device including: heart sounds, respiration rate, relative tidal volume, thoracic impedance, heart rate and activity. Objective: We examined the HF diagnostic sensor data during the periods prior to HFEs. To the extent these sensor data change prior to a HFE, they could be used to provide a warning that an HFE may soon occur. Methods: For all study patients with HFEs, and for each HF diagnostic sensor, we calculated a long-term (LT, -60 to -20 day) and a short-term (ST, -3 to -1 day) pre-event average. A matched-pair analysis for ST and LT values was performed for each HF diagnostic sensor using all HFEs with both LT and ST values. To prevent altered sensor data following a first HFE from influencing the LT value of the next HFE (if one existed), sensor data for 60 days after each HFE were excluded from analyses. Night heart rate was between midnight and 6:00 AM. A rapid shallow breathing index (RSBI) was computed as respiration rate/relative tidal volume. As a control, randomly selected patient-dates from patients that did not have any HFEs were used for the same matched-pair analyses. Results: Of 900 patients, 147 HFEs were experienced in 105 patients. Table 1 shows matched ST and LT values for HFEs, the number of matched pairs (N), the mean ± SE of the ST-LT differences and Wilcoxon p versus 0. The ST-LT differences from all HF sensors were highly significantly different in periods before HFEs. As expected due to the random selection of HFE times, none of the ST-LT differences from any HF sensors were significantly different from 0 in the control analyses. Conclusions: The HF diagnostic sensor data available to automated HFE detection algorithms changed significantly in the periods prior to actual HFEs but none of the sensor data changed in the periods before randomly selected times.Table 1HF Sensor data for LT (20–60 days) and ST (1–3 days) prior to HFEHF Diagnostic Sensor MeasureNLTSTMean DifferenceWilcoxon PFirst Heart Sound S1 (mG)902.091.94-0.16 ± 0.04<.0001Third Heart Sound S3 (mG)861.221.300.08 ± 0.03.0078S3/S1860.660.770.11 ± 0.02<.0001Thoracic Impedance (Ω)9245.442.8-2.65 ± 0.33<.0001Respiration Rate (med, br/min)9419.019.60.67 ± 0.15.0001Day-time RSBI*RSBI is Rapid Shallow Breathing Index. (br/min/Ω)929.7810.951.17 ± 0.19<.0001Night Heart Rate (br/min)9174.676.82.19 ± 0.61.0008Activity (minutes > 25 mG)9883.876.9-6.86 ± 2.38.0092* RSBI is Rapid Shallow Breathing Index. Open table in a new tab

Correspondence between the results of functional analyses and brief functional analyses

ABSTRACTPurpose: This study sought to examine the correspondence between brief functional analyses and more thorough functional analyses as described in the model of functional assessment proposed by Vollmer et al.1 Methods: A panel of trained clinicians indicated the presence/absence of specific functions of problem behavior based on graphic results from brief functional analyses and functional analyses conducted with 19 participants. These conclusions were compared across assessments. Results: The functions identified by the panel based on results of brief functional analyses had low correspondence with those of the more thorough functional analysis conducted with the same participants. Conclusions: Although brief-functional analyses appear regularly in clinical practice and the literature, findings from this study suggest that results may differ from those of more thorough functional analyses. Additional study is necessary to determine the cause of discrepant results between these two methodologies.

The 2017 hormone therapy position statement of The North American Menopause Society.

The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

Cost-comparison of two trabecular micro-bypass stents versus selective laser trabeculoplasty or medications only for intraocular pressure control for patients with open-angle glaucoma

Aim: Patients with open-angle glaucoma (OAG) whose intraocular pressure is not adequately controlled by one medication have several treatment options in the US. This analysis evaluated direct costs of unilateral eye treatment with two trabecular micro-bypass stents (two iStents) compared to selective laser trabeculoplasty (SLT) or medications only.Materials and methods: A population-based, annual state-transition, probabilistic, cost-of-care model was used to assess OAG-related costs over 5 years. Patients were modeled to initiate treatment in year zero with two iStents, SLT, or medications only. In years 1–5, patients could remain on initial treatment or move to another treatment option(s), or filtration surgery. Treatment strategy change probabilities were identified by a clinician panel. Direct costs were included for drugs, procedures, and complications.Results: The projected average cumulative cost at 5 years was lower in the two-stent treatment arm ($4,420) compared to the SLT arm ($4,730) or medications-only arm ($6,217). Initial year-zero costs were higher with two iStents ($2,810) than with SLT ($842) or medications only ($996). Average marginal annual costs in years 1–5 were $322 for two iStents, $777 for SLT, and $1,044 for medications only. The cumulative cost differences between two iStents vs SLT or medications only decreased over time, with breakeven by 5 or 3 years post-initiation, respectively. By year 5, cumulative savings with two iStents over SLT or medications only was $309 or $1,797, respectively.Limitations: This analysis relies on clinical expert panel opinion and would benefit from real-world evidence on use of multiple procedures and treatment switching after two-stent treatment, SLT, or polypharmaceutical initial approaches.Conclusions: Despite higher costs in year zero, annual costs thereafter were lowest in the two-stent treatment arm. Two-stent treatment may reduce OAG-related health resource use, leading to direct savings, especially over medications only or at longer time horizons.

Selection by a panel of clinicians and family representatives of important early morbidities associated with paediatric cardiac surgery suitable for routine monitoring using the nominal group technique and a robust voting process

ObjectiveWith survival following paediatric cardiac surgery improving, the attention of quality assurance and improvement initiatives is shifting to long-term outcomes and early surgical morbidities. We wanted to involve family representatives...

Validation of the Sinhala translation of the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms among women in Sri Lanka.

The objective of this study was to translate the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms (ICIQ-FLUTS) into Sinhala and validate the Sinhala translation for use in clinical practice. The ICIQ-FLUTS was translated into Sinhala in accordance with the ICIQ validation protocol. The Sinhala translation was validated by administering it to 133 women with FLUTS, mainly urinary incontinence and or urgency, and to 118 women with symptoms other than FLUTS during the period 25 October 2013 to 23 December 2016, in the Academic Obstetrics and Gynaecology Unit, Teaching Hospital Mahamodara, Galle, Sri Lanka. The Sinhala translation had good content validity (assessed by a panel of clinicians including a content specialist, and a group of women with and without FLUTS), good internal consistency (Cronbach's alpha coefficient in the range 0.69-0.75) was stable (no significant differences between median test-retest scores in a subgroup of 24 women with FLUTS), had good construct validity (marked difference between median scores in women presenting with and without FLUTS, p<0.001), and good responsiveness (marked improvements between scores before and after treatment, p<0.001). The Sinhala translation of the ICIQ-FLUTS is valid and reliable for assessing Sinhalese-speaking women with FLUTS, especially urinary incontinence and/or urgency.

Management of Central Venous Access Device-Associated Skin Impairment: An Evidence-Based Algorithm.

Patients relying on central venous access devices (CVADs) for treatment are frequently complex. Many have multiple comorbid conditions, including renal impairment, nutritional deficiencies, hematologic disorders, or cancer. These conditions can impair the skin surrounding the CVAD insertion site, resulting in an increased likelihood of skin damage when standard CVAD management practices are employed. Supported by the World Congress of Vascular Access (WoCoVA), developed an evidence- and consensus-based algorithm to improve CVAD-associated skin impairment (CASI) identification and diagnosis, guide clinical decision-making, and improve clinician confidence in managing CASI. A scoping review of relevant literature surrounding CASI management was undertaken March 2014, and results were distributed to an international advisory panel. A CASI algorithm was developed by an international advisory panel of clinicians with expertise in wounds, vascular access, pediatrics, geriatric care, home care, intensive care, infection control and acute care, using a 2-phase, modified Delphi technique. The algorithm focuses on identification and treatment of skin injury, exit site infection, noninfectious exudate, and skin irritation/contact dermatitis. It comprised 3 domains: assessment, skin protection, and patient comfort. External validation of the algorithm was achieved by prospective pre- and posttest design, using clinical scenarios and self-reported clinician confidence (Likert scale), and incorporating algorithm feasibility and face validity endpoints. The CASI algorithm was found to significantly increase participants' confidence in the assessment and management of skin injury (P = .002), skin irritation/contact dermatitis (P = .001), and noninfectious exudate (P < .01). A majority of participants reported the algorithm as easy to understand (24/25; 96%), containing all necessary information (24/25; 96%). Twenty-four of 25 (96%) stated that they would recommend the tool to guide management of CASI.