Previous Guidelines Research Articles

Revisiting Echocardiographic Ranges of Left Ventricular End-Diastolic Volume Index: An Analysis of the Discrepancies Between the 2006 and the 2015 Recommendation for Chamber Quantification Guidelines.

Indexed left ventricular end-diastolic volume (LVEDVi) is a left ventricle (LV) size marker. The "Recommendations for Chamber Quantification" guideline was published in 2006 and updated in 2015. Although the previous guideline maintained uniform cutoff points for both men and women, the latest revision introduced new thresholds that vary between genders. We evaluated the extent of change in labeled indexed LV diastolic volumes in men and women following the adoption of the 2015 guideline. Data were extracted from a web-based registry from March 2020 to October 2022. LV indexed volume variables were categorized on the basis of the 2006 and 2015 guidelines. Among the 7598 individuals, the classification of LVEDVi differed in 910 (12.0%) individuals. In 213 (5.5%) female subjects, substantial reclassification (i.e., transitioning from normal to moderate LV enlargement to mild to severe LV enlargement) occurred on the basis of the 2015 guideline. All females classified as having moderately abnormal LVEDVi according to the 2006 guideline were reclassified as having severely abnormal LVEDVi according to the 2015 guideline. Age, LV ejection fraction (LVEF), and significant aortic regurgitation (AR) were common factors contributing to the observed discrepancy in both men and women. Significant mitral regurgitation (MR) and regional or global motion abnormality were correlated with the reclassification of LVEDVi to higher abnormal partitions only in women. The observed disparities underscore the importance of ongoing dedicated research to reassess the range of indexed echocardiographic parameters, considering various outcomes and differences in countries.

Abstract P117: Provider Concordance to the Current 2017 High Blood Pressure (BP) Clinical Practice Guidelines and Patient Blood Pressure Control

Introduction: The AHA/ACC 2017 High BP guidelines introduced key changes, compared to previous guidelines, including a new hypertension definition (≥130/80 mm Hg) and lower medication thresholds for patients at cardiovascular risk. The impact of provider adherence to these guidelines on patient BP control has not been fully explored. Methods: We identified 3,749 new stage 1 hypertension patients (7,214 visits) and 11,013 new stage 2 hypertension patients (33,321 visits), aged ≥18, from the Vanderbilt University Medical Center database. We scrutinized outpatient BP levels, prescribed medications, follow-up visits, lab results, demographics, comorbid conditions, and physician notes from January 2018 to December 2022. This data was compared to hypertension treatment criteria developed from the 2017 guidelines that was validated by six hypertension experts. Active primary care patients (with 1 visit per year) were included. Mixed-effects Poisson regression and mixed-effects linear regression examined the relationship between guideline adherence and controlled BP (<130/80 mm Hg) and continuous BP, respectively. Results: Among stage 1 hypertension visits, 12.2% were treated with at least one antihypertensive drug according to guidelines, resulting in a 13% increase in BP control and a reduction in systolic BP by 2.02 mm Hg. For stage 2 hypertension visits, 26% received treatment with at least two first-line antihypertensive drug classes, leading to a 45% increase in BP control and reductions in systolic and diastolic BP by 3.79 mm Hg and 1.93 mm Hg, respectively. No significant difference in BP control was observed among stage 2 patients treated with two versus one first-line drug. Adherence to follow-up guidelines resulted in a 24% improvement in BP control for stage 1 patients and stage 2 patients when their follow-up visit occurred within 1 month. Subsequent follow-up visits within 1-month improved BP control by 34% if BP was not controlled previously. Additionally, 42.4% of patients with uncontrolled BP for 1 month received an increase in medication dose or a change/addition of medication class and showed a 7% increase in BP control within next month. Conclusion: Provider adherence to recommended antihypertensive drug treatment guidelines (12%-26%), follow-up assessments guidelines (29%-37%), and treatment intensification (42.4%) were poor. However, patients treated according to the guidelines showed significant improved BP control.

Revisiting design principles and guidelines for online makerspace services and programming in public libraries

PurposeThe purpose of this paper is to revisit previous design principles and guidelines for online makerspaces in public libraries (Kim et al., 2020) and expand the design principles with more updated implications and examples from the literature published during and after the COVID-19 pandemic.Design/methodology/approachThe authors reviewed recently published papers about online transitions of makerspaces, especially during and after the COVID-19 pandemic, summarized their implications and deduced applicable design principles and guidelines.FindingsThis paper proposes updated design principles and guidelines based on four key areas: Program and service design; Tools and materials; Facilitation; and Logistic support. These updated design principles considered a wider range of patrons that public library makerspaces may serve, the digital divide issues and logistic concerns that should be addressed beyond the scope of a single makerspace.Originality/valueThis paper compiles various lessons learned and strategies regarding online makerspaces and maker programming for public libraries and provides helpful design principles and guidelines for the continued use of online components for makerspace services and programs.

Peri-ictal psychiatric manifestations in people with epilepsy: An umbrella review.

We aimed to conduct an umbrella review to summarize the existing evidence regarding the prevalence of peri-ictal psychiatric manifestations (PM) in people with epilepsy (PWE) including pre-ictal, ictal, and postictal stages. Databases were searched up to June 2023 for systematic reviews (SR) of observational studies that included patients with epilepsy peri-ictal PM. Data selection, data extraction, and risk of bias assessment (with the AMSTAR-2 instrument) were performed by two independent reviewers. We performed a narrative synthesis using previous guidelines. We used a self-developed decision table according to the GRADE system adapted for narrative outcomes if the certainty of outcomes was not determined by systematic review authors. Four SRs were included comprising 66 primary studies (n = 10 217). Three SRs evaluated one period (pre-ictal, ictal, and postictal), and one did not determine it. During the pre-ictal period, the more prevalent symptom was confusion, although with a low certainty (due to the heterogeneity and serious risk of bias). One systematic review that only included case reports evaluated the ictal period, finding mood/anxiety disorders, psychosis, and personality changes. The postictal period included the most PM (anxiety: 45.0% and depressive symptoms: 43.0%), with very low certainty, due to risk of bias, potential publication bias, heterogeneity, and failure to report the confidence intervals. With very low certainty, epileptic periods are characterized by a wide spectrum of PM, being postictal symptoms the most prevalent, predominantly anxiety, and depressive symptoms. Further understanding of these PM of epilepsy could improve the attention of the people with epilepsy. In this review of reviews, we summarize the frequency in which psychiatric manifestations occur in relation to an epileptic seizure. A total of 10 217 patients were reported in the reviews. The most common manifestations included symptoms of anxiety and depression, as well as changes in the normal behavior of the patient. These manifestations occurred most frequently right after the seizure finished.

The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update.

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Evaluating the strength and quality of evidence in American heart association/American stroke association's guidelines for aneurysmal subarachnoid hemorrhage and spontaneous intracerebral hemorrhage

BackgroundClinical practice recommendations guide healthcare decisions. This study aims to evaluate the strength and quality of evidence supporting the American Heart Association (AHA)/American Stroke Association (ASA) guidelines for aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracerebral hemorrhage (ICH). MethodsWe reviewed the current AHA/ASA guidelines for aSAH and spontaneous ICH and compared with previous guidelines. Guidelines were classified based on the Class of recommendation (COR) and Level of evidence (LOE). COR signifies recommendation strength (COR 1: Strong; COR 2a: Moderate; COR 2b: Weak; COR 3: No Benefit/Harm), while LOE denotes evidence quality (LOE A: High-Quality; LOE B-NR: Moderate-Quality, Not Randomized; LOE B-R: Moderate-Quality, Randomized; LOE C-EO: Expert Opinion; LOE C-LD: Limited Data). ResultsFor aSAH, we identified 84 recommendations across 15 guideline categories. Of these, 31% were classified as COR I, 30% as COR 2a, 17% as COR 2b, and 18% as COR 3. In terms of LOE, 7% were based on LOE A, 10% on LOE B-R, 65% on LOE B-NR, 14% on LOE C-LD, and 5% on LOE C-EO. Compared to previous guidelines, there was a 46% decrease in LOE A, a 45% increase in LOE B, and an 11% decrease in LOE C. For spontaneous ICH, 124 guidelines were identified across 31 guideline categories. Of these, 28% were COR I, 32% COR 2b, and 9% COR 3. For LOE, 4% were based on LOE A, 35% on LOE B-NR, and 42% on LOE C-LD. Compared to previous guidelines, there was a 78% decrease in LOE A, an 82% increase in LOE B, and a 14% increase in LOE C. This analysis highlights that less than a third of AHA/ASA guidelines are classified as the highest class of recommendation, with less than 10% based on the highest LOE. ConclusionLess than a third of AHA/ASA guidelines on aSAH and spontaneous ICH are classified as the highest class of recommendation with less than 10% based on highest LOE. There appears to be a decrease in proportion of guidelines based on highest LOE in most recent guidelines.

Is It Useful to Repeat Blood Cultures in Endocarditis Patients? A Critical Appraisal.

Previous guidelines for endocarditis have suggested repeating blood cultures until they become negative, with limited evidence. Literature reviews were conducted (1) on the incidence of persistent bacteremia and association with outcome and (2) on timing of valve culture negativization to examine the claim for prolongation of antibiotic therapy starting from negative blood cultures. Persistent bacteremia and fever may be present in the first 3 days of endocarditis, despite treatment, and are more common in Staphylococcus (especially MRSA) and Enterococcus species. Persistent bacteremia (48-72 h), persistent infection (day 7), and new onset septic shock are related and predict in-hospital mortality. It is, however, persistent infection at day 7 and septic shock that primarily determine the infectious course of endocarditis, and not persistent bacteremia. Valve cultures at surgery become negative in most cases (>85-90%) after 14-21 days of antibiotic therapy, with no calculated benefit for prolonging therapy after 21 days. Persistent infection at 7 days after appropriate antibiotic therapy is a better key event for prognosis then positive or negative blood cultures at 48-72 h. Therapy prolongation from the day of negative blood cultures is not reasonable. There is no need to survey blood cultures in endocarditis patients after starting therapy.

Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms.

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Preclinical SPECT and PET: Joint EANM and ESMI procedure guideline for implementing an efficient quality control programme.

The aim of this guideline is to provide recommendations for the implementation of an effective and efficient quality control (QC) programme for SPECT and PET systems in a preclinical imaging lab. These recommendations aim to strengthen the translational power of preclinical imaging results obtained using preclinical SPECT and PET. As for clinical imaging, reliability, reproducibility, and repeatability are essential when groups of animals are used in a longitudinal imaging experiment. The larger the variability of the imaging endpoint, the more animals are needed to be able to observe statistically significant differences between groups. Therefore, preclinical imaging requires quality control procedures to maintain reliability, reproducibility, and repeatability of imaging procedures, and to ensure the accuracy and precision of SPECT and PET quantification. While the Physics Committee of the European Association of Nuclear Medicine (EANM) has already published excellent procedure guidelines for Routine Quality Control Recommendations for Nuclear Medicine Instrumentationthat also includes procedures for small animal PET systems, and important steps have already been made concerning preclinical quality control aspects, this new guideline provides a review and update of these previous guidelines such that guidelines are also adapted to new technological developments.

Thoracic Society of Australia and New Zealand clinical practice guideline on adult home oxygen therapy.

This Thoracic Society of Australia and New Zealand Guideline on the provision of home oxygen therapy in adults updates a previous Guideline from 2015. The Guideline is based upon a systematic review and meta-analysis of literature to September 2022 and the strength of recommendations is based on GRADE methodology. Long-term oxygen therapy (LTOT) is recommended for its mortality benefit for patients with COPD and other chronic respiratory diseases who have consistent evidence of significant hypoxaemia at rest (PaO2 ≤ 55 mm Hg or PaO2 ≤59 mm Hg in the presence of hypoxaemic sequalae) while in a stable state. Evidence does not support the use of LTOT for patients with COPD who have moderate hypoxaemia or isolated nocturnal hypoxaemia. In the absence of hypoxaemia, there is no evidence that oxygen provides greater palliation of breathlessness than air. Evidence does not support the use of supplemental oxygen therapy during pulmonary rehabilitation in those with COPD and exertional desaturation but normal resting arterial blood gases. Both positive and negative effects of LTOT have been described, including on quality of life. Education about how and when to use oxygen therapy in order to maximize its benefits, including the use of different delivery devices, expectations and limitations of therapy and information about hazards and risks associated with its use are key when embarking upon this treatment.

Management of Clostridioides difficile infection: an Italian Delphi consensus.

Clostridioides difficile infection (CDI), a leading cause of nosocomial deaths, is a microbiota-mediated disease. As such, the use of broader spectrum antibiotics, such as vancomycin and metronidazole, can prime the gastrointestinal tract to become more prone to CDI recurrences. Fidaxomicin, a narrow-spectrum antibiotic, has been demonstrated to be superior in preventing recurrence and in preserving the intestinal microbiota; however, widespread employment worldwide has been hindered due to high acquisition costs. To integrate the currently available guidelines on the management of CDI and to shed light on the timeliest employment of fidaxomicin. An expert panel was gathered to obtain consensus using Delphi methodology on a series of statements regarding the management of CDI and on appropriate antibiotic use. Consensus was reached on 21 of the 25 statements addressing the management of CDI. Delphi methodology was used to achieve consensus on the management of CDI, on the identification of patients at risk of recurrences or severe infection, and on the most appropriate use of fidaxomicin, with the final aim of fostering clinical practice application of treatment algorithms proposed by previous guidelines, in absolute synergy. It could be an important tool to promote more appropriate and cost-effective CDI treatments in European settings with limited resources, like Italy.

Management of Metabolic-Associated Fatty Liver Disease/Metabolic Dysfunction-Associated Steatotic Liver Disease: From Medication Therapy to Nutritional Interventions.

Non-alcoholic fatty liver disease (NAFLD) is a common long-lasting liver disease that affects millions of people around the world. It is best identified with a hepatic fat build-up that ultimately leads to inflammation and damage. The classification and nomenclature of NAFLD have long been a controversial topic, until 2020 when a group of international experts recommended substituting NAFLD with MAFLD (metabolic dysfunction-associated FLD). MAFLD was then terminologically complemented in 2023 by altering it to MASLD, i.e., metabolic dysfunction-associated steatotic liver disease (MASLD). Both the MAFLD and the MASLD terminologies comprise the metabolic element of the disorder, as they offer diagnostic benchmarks that are embedded in the metabolic risk factors that underlie the disease. MASLD (as a multisystemic disease) provides a comprehensive definition that includes a larger population of patients who are at risk of liver morbidity and mortality, as well as adverse cardiovascular and diabetes outcomes. MASLD highlights metabolic risks in lean or normal weight individuals, a factor that has not been accentuated or discussed in previous guidelines. Novel antihyperglycemic agents, anti-hyperlipidemic drugs, lifestyle modifications, nutritional interventions, and exercise therapies have not been extensively studied in MAFLD and MASLD. Nutrition plays a vital role in managing both conditions, where centralizing on a diet rich in whole vegetables, fruits, foods, healthy fats, lean proteins, and specific nutrients (e.g., omega-3 fatty acids and fibers) can improve insulin resistance and reduce inflammation. Thus, it is essential to understand the role of nutrition in managing these conditions and to work with patients to develop an individualized plan for optimal health. This review discusses prevention strategies for NAFLD/MAFLD/MASLD management, with particular attention to nutrition and lifestyle correction.

The Clinical Incorporation of the 2017 Classification of Periodontal Disease Conditions Part II: The Association Between Clinical Parameters and Gender.

Background The implementation of the new classification system guided clinicians in the best way for disease diagnosis and patient management. The advent of definitions such as clinical gingival health additionally helped in distinguishing between intact and reduced periodontium. The purpose behind introducing new systems was to guide practitioners to improve on managing the requirements of the patients effectively. It also enables professionals to concentrate on clinical practice, and it can be suggested that readers who are concentrating on research make use of the global classification system. In this study, we present a diagnostic approach for periodontal diseases that supports the innovative classification system in relation to gender while remaining compatible with previous guidelines. Aim The present study focuses on the relationship between gender association and the clinical parameters in periodontitis patients that would support the new classification system. Materials and methods This was a retrospective, cross-sectional, observational study consisting of patient data obtained from past patient records who were diagnosed with periodontitis. Results The data analysis results showed that 95% of the population was similarly distributed across the genders in terms of frequency, and there was minimal statistically significant differencebetween the genderswhen compared to the clinical parameters. However, there was a statistically significant difference in the specific clinical characteristics, such as recession, which impacted 48.6% of male patients, and the presence of local factors, which affected 43.2% of female patients, in addition to the 59.4% localized involvement of periodontitis. All the data were analyzed using the SPSS softwareversion 20 (IBM SPSS Statistics, Armonk, NY). The chi-square test was used to evaluate the descriptive analysis and frequency tables. Conclusion The addition of correlating clinical parameterswith data based on gender had no effect on the new classification system. Meanwhile, it can be used as an adjunct to evaluate the distribution and extent of disease progression among genders.

Association of RBC Transfusion Thresholds and Outcomes in Medical Patients With Acute Respiratory Failure Supported With Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study

The hemoglobin value to trigger RBC transfusion for patients receiving venovenous extracorporeal membrane oxygenation (ECMO) is controversial. Previous guidelines recommended transfusing to a normal hemoglobin level, but recent studies suggest that more RBC transfusions are associated with increased adverse outcomes. Is implementation of different institutional RBC transfusion thresholds for patients receiving venovenous ECMO associated with changes in RBC use and patient outcomes? This single-center retrospective study of patients receiving venovenous ECMO used segmented regression to test associations between implementation of institutional transfusion thresholds and trends in RBC use. Associations with secondary outcomes, including in-hospital survival, also were assessed. The study included 229 patients: 91 in the no threshold cohort, 48 in the hemoglobin< 8 g/dL cohort, and 90 in the hemoglobin< 7 g/dL cohort. Despite a decrease in number of RBC units transfused per day of ECMO support after implementation of different thresholds (mean ± SD: 0.6 ± 1.0 in the no threshold cohort, 0.3 ± 0.8 in the hemoglobin< 8 g/dL cohort, and 0.3 ± 1.1 in the hemoglobin< 7 g/dL cohort; P< .001), segmented regression showed no association between implementation of transfusion thresholds and changes in trends in number of RBC units per day of ECMO. We observed an increased hazard of death in the no threshold cohort compared with the hemoglobin< 8 g/dL cohort (adjusted hazard ratio [aHR], 2.08; 95%CI, 1.12-3.88) and in the hemoglobin< 7 g/dL cohort compared with the hemoglobin< 8 g/dL cohort (aHR, 1.93; 95%CI, 1.02-3.62). No difference was found in the hazard of death between the no threshold and hemoglobin< 7 g/dL cohorts (aHR, 1.08; 95%CI, 0.69-1.69). We observed a decrease in number of RBC units per day of ECMO over time, but changes were not associated temporally with implementation of transfusion thresholds. A transfusion threshold of hemoglobin< 8 g/dL was associated with a lower hazard of death, but these findings are limited by study methodology. Further research is needed to investigate optimal RBC transfusion practices for patients supported with venovenous ECMO.

IDEN Consensus on Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy

Antithrombotic agents, including antiplatelet agent and anticoagulants are widely used in Korea due to increasing incidence of cardio-cerebrovascular disease and aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. Clinical practice guideline regarding this issue which was developed by the Korean Society of Gastrointestinal Endoscopy was published in 2020. However, since then, new evidence has emerged for the use of dual antiplatelet therapy and direct anticoagulant management, and revised guidelines were issued in the US and Europe. Accordingly, the previous guidelines were revised, cardiologists also participated in the development group, and the recommendations went through a consensus process among international experts. This guideline presents 14 recommendations made according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and was reviewed by multidisciplinary experts. This guideline provides useful information that can assist endoscopists in the management of patients on antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

CaReL Guideline: A Consensus-Based Guideline on Case Reports and Literature Review (CaReL)

Introduction Clinical case reports enrich medical literature by presenting rare medical issues. However, case reports that do not adhere to a standard template often lack rigor and limit their usefulness in clinical guidance. Several guidelines for reporting case reports have been structured, while further improvements are still required. The current guideline (CaReL) aims to enhance the comprehensiveness of case reports by integrating a detailed literature review. Methods In total, 56 researchers were selected based on specific publication criteria for structuring the guidelines. The guideline development was based on a two-step consensus process, including a literature review and survey distribution. Responses underwent scrutiny to ensure reliability and validity. Content validity was assessed, with revisions made to achieve a content validity index exceeding 0.78. The guideline's feasibility and effectiveness were evaluated by pilot testing, with feedback incorporated for finalization, ensuring the robustness and practicality of the guideline. Results The CaReL guidelines can improve the quality of case reports through a comprehensive checklist with an increased emphasis on literature review. In addition to traditional sections with their subsections discussed in previous guidelines, the checklist also focuses on literature review in the abstract and discussion. Conclusion The CaReL guidelines offer a comprehensive structure for documenting case reports. They highlight the importance of incorporating a literature review to better introduce medical issues to readers and scholars and embedding reported cases into the current scientific state of the art. Implementing these guidelines can promote knowledge sharing and improve patient care

Blood Pressure Management in Early Aneurysmal Subarachnoid Hemorrhage: A National Cross-Sectional Survey of Canadian Intensivists and Cerebrovascular Neurosurgeons.

In aneurysmal subarachnoid hemorrhage (aSAH), rebleeding of the culprit aneurysm is associated with significant morbidity and mortality. Blood pressure reduction to specific target levels, with the goal of preventing rebleeding, has been a mainstay of care prior to definitively securing the aneurysm. Clinical practice guidelines have recently changed and no longer recommend specific blood pressure targets. This survey aims to identify the reported practice patterns and beliefs regarding blood pressure management during the early phase of aSAH. We conducted a self-administered, Web-based survey of critical care physicians and cerebrovascular neurosurgeons practicing in Canada. The questionnaire contained 21 items, including 3 case-based scenarios to elicit blood pressure target selection, both before and after aneurysm securing. In the presecured period, systolic blood pressures of 160 mm Hg (50% [144 of 287]) and 140 mm Hg (42% [120 of 287]) were the most frequently selected upper-limit targets. In the postsecured period, a systolic blood pressure of 180 mm Hg (32% [93 of 287]) was the most frequently selected upper-limit target, but there was a wide distribution of targets selected across all three cases ranging from 100 to > 200 mm Hg. A mean arterial pressure of 65 mm Hg was the most common lower-limit target in both the presecured and postsecured periods. There was little change in blood pressure targets with increasing clinical severity. Predictors of higher or lower blood pressure target selection and barriers to implementation of the desired target were identified. During the presecured period, nearly half of the reported upper-limit blood pressure targets are lower than previous guideline recommendations. These targets remain consistent despite increasing clinical severity and could potentially exacerbate cerebral ischemia and negatively impact clinical outcomes. In the postsecured period, there is wide variation in the reported blood pressure targets. A clinical trial is urgently needed to guide decision-making.

Management of Neonatal Hyperbilirubinemia: Shedding Light on the American Academy of Pediatrics 2022 Clinical Practice Guideline Revision.

Neonatal hyperbilirubinemia is one of the most common conditions managed by pediatricians. Although many infants are affected, most will experience complete resolution without complication. Acute bilirubin encephalopathy and kernicterus are rare yet debilitating sequelae of severe hyperbilirubinemia that can be avoided through careful monitoring and treatment with phototherapy. Appropriate management of neonatal hyperbilirubinemia must balance the risks of these severe conditions with the effects of overtreatment. Released in 2022, the American Academy of Pediatrics revised the clinical practice guideline for the management of hyperbilirubinemia, which aims to provide that balance through updates to the previous guideline. This article will provide the reader with (1) an evidence-based harm and benefit analysis of the guideline, (2) an overview of key changes and clarifications made in the new guideline, and (3) a practical summary of guideline updates. [Pediatr Ann. 2024;53(6):e208-e216.].

La gestione della piastrinopenia immune acuta in età pediatrica

This report summarizes the most relevant issues of the document that the Working Group on Coagulation Disorders of the Italian Association of Paediatric Haematology and Oncology (AIEOP) developed to gather shared expert opinions on the management of newly diagnosed idiopathic thrombocytopenic purpura (ITP), updating previous guidelines and providing recommendations to paediatricians. These recommendations are not intended to be standards or fixed rules but rather a tool to support paediatricians in the management of the diagnostic work-up and treatment of children with newly diagnosed ITP

#560 The representation of multimorbidity and frailty in the development and validation of kidney failure risk prediction models – a systematic review

Abstract Background and Aims Prognostic models that identify individuals with chronic kidney disease (CKD) at highest risk of developing kidney failure help clinicians to make decisions and deliver precision medicine. People with CKD are very likely to have multiple long-term health conditions (multimorbidity) and often experience frailty. These factors impact progression of kidney disease and influence the risk of other outcomes such as death. It is unclear to what extent prognostic models, that estimate the risk of kidney failure, consider the impact of multimorbidity and frailty and whether these models are valid in such sub-populations. This systematic review (CRD42022347295) describes and evaluates the representation of multimorbidity and frailty within cohorts used to develop and/or validate prognostic models assessing the risk of kidney failure in individuals with CKD. The review aims to determine if multimorbidity or frailty has been considered in relation to prediction of kidney failure and if reliable prognostic models exist for use in this population. Method We included studies that described the derivation, validation or update of a kidney failure prognostic model (outcome assessed at ≥2 years) for use in adults with CKD and reported at least one measure of either discrimination or calibration. The primary outcome for the review was the representation of multimorbidity or frailty in these models. An electronic search for published peer-reviewed articles involved MEDLINE, CINAHL Plus and the Cochrane Library – CENTRAL and was supplemented with manual review of references from previous systematic reviews and clinical guidelines. Results A total of 97 studies, reporting 121 different kidney failure prognostic models were identified. A total of 2 925 413 participants and 149 380 kidney failure events were included across all studies. Included participants had a mean age of 58.9 years (SD 9.6), 44.4% were female, with a mean eGFR of 47.5 ml/min/1.73 m2 (SD 10.7). Only two studies reported multimorbidity, measured by Elixhauser Comorbidity Index and Charlson Co-morbidity Index (CCI), and a single study reported a self-reported proxy frailty measure. The rates of specific co-morbidities were reported in a greater proportion of studies: 67.0% (n = 65) studies reported baseline data on diabetes, 54.6% (n = 53) reported hypertension, and 39.2% (n = 38) reported cardiovascular disease. No studies included frailty in model development and only one study considered multimorbidity as a predictor variable (via CCI). No studies assessed model performance in populations with multimorbidity. A single study assessed clinical utility of a model and referral algorithms considering frailty and the risk of kidney failure and death. Conclusion There is a paucity of kidney failure risk prediction models that consider the impact of multimorbidity and/or frailty in adults with CKD, resulting in a lack of clear evidence-based practice and guidance for multimorbid or frail individuals. These knowledge gaps should be explored to help clinicians know whether these models can be used for patients who experience multimorbidity and/or frailty.