Procedural Guidelines Research Articles

Einwilligungsfähig oder nicht? Zur Praxis der Prüfung von Einwilligungsfähigkeit im klinischen Alltag und deren Herausforderungen

Background/ObjectivesThe capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient’s CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient’s CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application. MethodsBased on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme. ResultsThe majority of respondents reported that “sometimes to very often” they had doubts about their patients’ CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of “partially important” to “very important”. Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC. Discussion and conclusionOverall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients’ CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

Manajemen Pengembangan Pembelajaran Kitab Kuning

Kitab kuning viewed as theory and values contributor that followed al-Quran and Hadis Nabi as a background. In pesantren world, kitab kuning position are very strategic because it used as text book, references, and curriculum within pesantren education system. Aside from being religion procedure guideline,kitab kuning also functioned as universalreferences on responding every life challenge among pesantren people. Presevartion of learning method with kitab kuning in pesantren has been running constantly and culturally being special characteristic of pesantren. There is a few kitab kuning categorization which is based on its'characteristic, meaning content, serving proportion, writing creativity, and description appearance. The learning method of kitab kuning in salafiyah pesantren will not be separated from conventional traditional method use. These are few learning method we talking about; wetonan or bandongan, sorogan and hafalan (tahfidz) and munazharah (musyawarah/muzkarah). There is also learning evaluation in the learning method of kitab kuning.

Risk Risk Assessment and Development of Access Control Information Security Governance Based on ISO/IEC 27001:2013 At XYZ University

The rapid development of information technology at this time also has an impact on the use of information technology in the university environment. XYZ University as a university that has quite a lot of students also applies information technology to support their distance learning. The role of information technology is quite crucial and important. Unfortunately, the issue of information security which is an important part of information technology often gets less attention. Its undeniable that the emergence of threats or weaknesses in information technology can disrupt the course of service activities using information technology. Therefore, it is necessary to manage information technology and risk-based document standard procedures as outlined in governance to manage emerging threats or weaknesses. ISO/IEC 27001:2013 is an framework of information security management system that can be used as a basis for managing information security. This study identifies assets, threats, weaknesses, risk analysis, BIA, risk assessment, and risk mapping based on clauses to produce recommendations for policy documents, procedures, and work instructions to improve information security control based on ISO 27001:2013 clauses. Considering its high risk value, this study produced several recommendations for security documents, namely 5 policy documents, 6 procedure guidelines, 8 work instructions, and 12 forms.

Role of protective stoma after primary anastomosis for generalized peritonitis due to perforated diverticulitis—DIVERTI 2 (a prospective multicenter randomized trial): rationale and design (nct04604730)

BackgroundTraditionally, patients with peritonitis Hinchey III and IV due to perforated diverticulitis were treated with Hartmann’s procedure. In the past decade, resection and primary anastomosis have gained popularity over Hartmann’s procedure and recent guidelines recommend Hartmann’s procedure in two situations only: critically ill patients and in selected patients with multiple comorbidity (at high risk of complications).The protective stoma (PS) is recommended after resection with primary anastomosis, however its interest has never been studied. The aim of this trial is to define the role of systematic PS after resection and primary anastomosis for peritonitis Hinchey III and IV due to perforated diverticulitis.Methods/designThis DIVERTI 2 trial is a multicenter, randomized, controlled, superiority trial comparing resection and primary anastomosis with (control group) or without (experimental group) PS in patients with peritonitis Hinchey III and IV due to perforated diverticulitis.Primary endpoint is the overall 1 year morbidity according to the Clavien–Dindo classification of surgical complications. All complications occurring during hospitalization will be collected. Late complications occurring after hospitalization will be collected during follow-up.In order to obtain 80% power for a difference given by respective main probabilities of 67% and 47% in the protective stoma and no protective stoma groups respectively, with a two-sided type I error of 5%, 96 patients will have to be included in each group, hence 192 patients overall. Expecting a 5% rate of patients not assessable for the primary end point (lost to follow-up), 204 patients will be enrolled.Secondary endpoints are postoperative mortality, unplanned reinterventions, incisional surgical site infection (SSI), organ/space SSI, wound disruption, anastomotic leak, operating time, length of hospital stay, stoma at 1 year after initial surgery, quality of life, costs and quality-adjusted life years (QALYs).DiscussionThe DIVERTI 2 trial is a prospective, multicenter, randomized, study to define the best strategy between PS and no PS in resection and primary anastomosis for patients presenting with peritonitis due to perforated diverticulitis.Trial registrationClinicalTrial.gov: NCT04604730 date of registration October 27, 2020. https://clinicaltrials.gov/ct2/show/NCT04604730?recrs=a&cond=Diverticulitis&draw=2&rank=12.

Abstract B024: Exploring the temporal dynamics of pancreatic cancer through post-mortem tumor analysis: A pilot case study

Abstract Introduction Pancreatic cancer is a lethal disease with an incidence little higher than the mortality rate. Great advances in oncology have been made in recent years with new treatment strategies for many cancers, leading to substantial improvement in patient outcome. The prognosis for pancreatic cancer patients, however, remains dismal and chemotherapy is still standard of care. An increased understanding of the temporal evolution and resistance mechanisms of pancreatic cancer during chemotherapy is necessary to improve patient outcome. To this end, the Chemotherapy, Host response And Molecular dynamics in Periampullary cancer study (CHAMP) was initiated in 2018. It is an ongoing, prospective observational trial in which blood samples are taken from patients at each chemotherapy cycle. Recently, the CHAMP- Extended Tissue Analysis (ETA) study was initiated, wherein selected patients enrolled in the CHAMP-study undergo targeted autopsies. The aim of this study was to compare the expression of selected immunohistochemical (IHC) markers and the quality of DNA in tumor tissue from an ante-mortem resected metastasis to the ileum and post-mortem collected tumor tissue in the first patient enrolled in the CHAMP-ETA study. Methods The autopsy was performed by a senior pathologist in accordance with standard procedure guidelines and all visible tumor was collected for analysis. The post-mortem interval (PMI) was 44 hours. Multiple tissue cores from formalin-fixed paraffin-embedded tumor tissue from the surgical resection and different tumor sites from the autopsy were assembled into a single tissue microarray (TMA) block. DNA was extracted from adjacent tissue cores obtained in parallel with the TMA-construction, and the quality examined by qPCR. IHC staining of standard diagnostic markers CK7, CK20, CDX2 and the proliferation marker Ki67 was performed on the TMA. Results In line with the expected, both normal and tumor tissue in the pancreas displayed a higher degree of autolysis compared to the metastases. Tumor areas surrounded by a more dense stroma tended to be less autolytic. CK20 and CDX2 expression was negative in all samples, both ante-mortem and post-mortem. CK7 was highly expressed in all tumor samples with an ever-stronger intensity in the post-mortem samples. Of note, CK7 was also strongly expressed in the tumor stroma of the post-mortem samples, but not in the pre-mortem samples. Ki67 expression was significantly higher in ante-mortem than in post-mortem samples. The extracted DNA was of sufficient quality in all tested post-mortem samples. Conclusion The results demonstrate that the DNA quality is sufficient after a PMI of 44 hours. The conditions for IHC staining are less optimal but may be sufficient for some markers. Access to post-treatment tumor tissue is an important complement to on-treatment biomarker studies, and of vital importance to understand the molecular events leading to terminal disease. Citation Format: Sofie Olsson Hau, Jasmine Webster, Alexandra Petersson, Jakob Eberhard, David Gisselsson, Karin Jirström. Exploring the temporal dynamics of pancreatic cancer through post-mortem tumor analysis: A pilot case study [abstract]. In: Proceedings of the AACR Special Conference on the Evolutionary Dynamics in Carcinogenesis and Response to Therapy; 2022 Mar 14-17. Philadelphia (PA): AACR; Cancer Res 2022;82(10 Suppl):Abstract nr B024.

Development and validation of a ultraperformance liquid chromatography-tandem mass spectrometry method for quantifying free and total dabigatran in human plasma: An application for a bioequivalence study.

Dabigatran etexilate mesylate (DABE), a prodrug, quickly changes into dabigatran (DAB) after its oral administration. Accordingly, detecting DABE in plasma is practically unmanageable. An ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) technique was developed and validated to compute free DAB in participants. For the first time, the central composite design, a type of response surface methodology, was applied for optimizing variables affecting the cleavage of glucuronide bond. In addition, the pharmacokinetic parameters of generic medication (okanadab) were determined, and the obtained outcomes were compared with those of the branded drug (pradaxa). The sample preparation was done using methanol as a protein precipitant and the separation was achieved using an ACQUITY UPLC BEH C18 column (2.1 × 50 mm, 1.7 μm). The elution was isocratically conducted using 10mM ammonium formate:methanol (72:28, v/v) as a mobile phase and the flow rate was 0.25 mL/min. Multiple reaction monitoring and positive electrospray ionization were used. The determination was performed within 1min, and the calibration growth curve was established over a range of 1.19-475 ng/mL using DAB-d3 as a tagged internal standard. Bioequivalence research was validated following the US Food and Drug Administration (US FDA) guidelines for bioanalytical procedures and acceptable outcomes were achieved. The outcomes for okanadab and pradaxa did not differ significantly.

Practices for accessing hormone therapy in male to female transgenders in Maharashtra, India

PurposeHormone Replacement Therapy (HRT) is important for gender reassignment procedures for transgender persons in India. The study explores practices of male-to-female transgenders to access HRT for feminization procedures in Maharashtra, India. MethodsThe first participant for this qualitative exploratory study was recruited from a community-based organization. Further participants were recruited using snowball sampling until data saturation was reached. In-depth interviews (IDI) were conducted over video platforms after written/audio-visual consent of the participants. The recorded interviews were transcribed into verbatim. The data, after each interview, were analyzed through thematic content analysis using inductive approach. The prevalent practices were identified from relevant phrases, sentences, and terms of the transcripts and were labeled and coded. ResultsThe study reported lack of acceptance and support from family for HRT. Some participants were abandoned or chose to run from their homes and undergoing transition without family support. Participants reported accessing HRT over-the-counter and practiced self-medication due to lack of affordability, scarcity of trained doctors and persisting stigma and discrimination at healthcare facilities. Those who self-medicated were following similar drug regimens administered to their peers or self-adjusted doses on the basis of physical achievements. Participants of Hijra kinships were dependent on their leaders to avail HRT services. ConclusionsThere is a need to develop standard HRT guidelines for feminization procedures and include HRT services in health programs. There is a necessity to train healthcare professionals and establish a center of excellence for these procedures in Maharashtra.

Countdown to perovskite space launch: Guidelines to performing relevant radiation-hardness experiments

<h2>Summary</h2> Perovskite photovoltaics (PVs) are under intensive development for promise in terrestrial energy production. Soon, the community will find out how much of that promise may become reality. Perovskites also open new opportunities for lower cost space power. However, radiation tolerance of space environments requires appropriate analysis of relevant devices irradiated under representative radiation conditions. We present guidelines designed to rigorously test the radiation tolerance of perovskite PVs. We review radiation conditions in common orbits, calculate nonionizing and ionizing energy losses (NIEL and IEL) for perovskites, and prioritize proton radiation for effective nuclear interactions. Low-energy protons (0.05–0.15 MeV) create a representative uniform damage profile, whereas higher energy protons (commonly used in ground-based evaluation) require significantly higher fluence to accumulate the equivalent displacement damage dose due to lower scattering probability. Furthermore, high-energy protons may "heal" devices through increased electronic ionization. These procedural guidelines differ from those used to test conventional semiconductors.

Factors affecting the professional functioning of health care workers during the COVID-19 pandemic: A cross-sectional study.

AimTo examine personal and organisational factors related to professional functioning of nurses and physicians during the COVID‐19 pandemic.BackgroundExposure to COVID‐19‐related stressors has been associated with lower self‐reported professional functioning among health care workers.MethodsA cross‐sectional study among 115 hospital workers during the COVID‐19 pandemic in Israel was designed to explore (a) personal professional functioning, (b) clarity of guidelines, (c) work organisation by the management, and (d) health care workers' feeling of contribution to a global effort.ResultsA feeling of contribution to a global effort while treating patients with COVID‐19 mediated the relationships between work organisation by the management and professional functioning (β = .05, p < .05). The clarity of guidelines for routine procedures (β = .21, p < .05) and a feeling of β contribution to a global effort (β = .34, p < .01) positively predicted professional functioning of nurses and physicians during COVID‐19 pandemic (R 2 = .19, p < .01).ConclusionsIn order to achieve optimal functioning of health care workers in an emergency, managers should provide clear guidelines and promote workers' feelings of contribution to a global effort.Implications for Nursing ManagementThe provision of clear guidelines and protocols is essential for efficient emergency management. Expressing appreciation for health care workers and providing positive feedback may improve professional functioning.

We Have Come Full Circle for Venous Thromboembolism Prevention: Commentary on an article by Emanuele Chisari, MD, et al.: "Aspirin Is an Effective Prophylaxis for Venous Thromboembolism in Ambulatory Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty".

Commentary In their study, Chisari et al. add to the recent literature that has shown that aspirin is as effective as other anticoagulants at preventing symptomatic venous thromboembolism (VTE) for surgical lower-extremity conditions. This evidence may be practice-changing for surgeons treating patients with hip fractures and once again elevates aspirin to a preferred prophylactic option. After decades of opinion and evidence that aspirin was not the best prophylaxis for preventing VTE, the pendulum is now strongly swinging back toward aspirin. Studies on elective hip and knee arthroplasty provide the highest-quality evidence to answer important questions about preventing VTE. In patients undergoing elective procedures, tight study control is more feasible than in other conditions in which VTE is a high risk, such as trauma. Previous guidelines for these elective surgical procedures indicated that aspirin was less effective than more powerful anticoagulants. However, more recent studies have suggested otherwise. For instance, a systematic review and meta-analysis of randomized clinical trials found that aspirin for VTE prevention was as safe and effective as other anticoagulants1. Aspirin is now routine for standard-risk patients undergoing hip or knee arthroplasty, but patients with other risk factors for VTE are still considered for more powerful anticoagulation. One such risk factor is trauma. Patients with hip fractures are at extremely high risk for VTE, for reasons including that trauma is a procoagulant, there could be endothelial damage, there could be relative immobility, and hip fractures tend to occur in elderly patients with other comorbid risk factors. Because of these increased risks, patients with hip fracture have not commonly been treated with aspirin and other anticoagulants have been recommended. For instance, in a 2019 update on current practice, the authors noted that, for patients with hip fracture, other chemoprophylaxis has been found to be more effective than aspirin2. In the current study, Chisari et al. show that aspirin prophylaxis for patients with femoral neck fracture treated with arthroplasty is equivalent to prophylaxis with other anticoagulants. The patients in the aspirin group actually had lower rates of VTE, but, when statistical balancing through propensity matching was employed, there was no difference in the VTE rates between the 2 groups. This suggests that aspirin could be used routinely for VTE prophylaxis in these patients. Surgeons should consider a few other factors before broadly accepting the results of this study. First, this was a retrospective study, and it is clear that aspirin was chosen for patients with a lower risk of VTE. However, the propensity matching employed, utilizing an accepted VTE risk score, increases confidence that similar groups of patients were compared. Second, all patients were mobilized on the same day as or the day after the surgical procedure, and all had mechanical compression devices as part of the treatment protocol. The absence of these best practices could have changed the results. Finally, even among the trauma group, there were patients who were higher-risk than others. Exactly which categories of these high-risk patients benefit from more powerful anticoagulation remains unknown. In 1 study of hip and knee arthroplasty, aspirin was equivalent to other anticoagulants even in high-risk patients3. It is interesting to speculate why there is new evidence about a drug that has been studied for decades. After all, aspirin is not new for VTE prophylaxis, so why is it making this data-driven resurgence? Here are a few speculative answers. Perhaps we now have better research or perhaps the disease process has changed in some way. These seem unlikely. Maybe there was bias against the simpler option of aspirin in earlier studies. There clearly has been a shift in studies toward relying on only clinically important outcome measures. For instance, in the current study, only clinically apparent deep vein thrombosis or pulmonary embolism was included as outcomes, compared with surrogates based on imaging studies or ultrasound frequently used in the past. This might be an important difference. Finally, as in this study, aspirin is now combined with early mobilization and mechanical compression devices, things that were not routine in earlier studies. Although it is hard to know what has driven the strong trend toward literature that demonstrates aspirin equivalence to other anticoagulants, this change does give me the feeling of having gone full circle and now we are back to where we started with aspirin.

Phacoemulsification with vitreous loss using phacoemulsifier and vitrector concurrently: bimanual-bipedal technique.

Vitreous loss is one of the adverse complications that can occur during phacoemulsification. Once vitreous loss is identified, procedural guidelines advise that phacoemulsification be ceased and the probe carefully withdrawn to minimize traction on the vitreous. Bimanual-bipedal technique described in this study holds the phacoemulsification probe in place and inserts the vitrectomy cutter through the pars plana port with the other hand. After removal of vitreous around the phacoemulsification tip, the vitrectomy cutter is switched to a cutting rate of zero. phacoemulsification can then be resumed with the vitrectomy cutter as a retainer of the lens fragments, similar to the hook of bimanual technique. Lens fragments are synergistically retained through aspiration between the vitrectomy cutter and phacoemulsification probe to prevent displacement. The bimanual-bipedal technique may offer a more streamlined and potentially safer approach for phacoemulsification with vitreous loss.

Uncovering the Mechanism of Size Effect on the Thermomechanical Properties of Highly Cross-Linked Epoxy Resins.

Epoxy resins are widely used as matrix resins, especially for carbon-fiber-reinforced plastic, due to their outstanding physical and mechanical properties. To date, most research into cross-linking processes using simulation has considered only a distance-based criterion to judge the probability of reaction. In this work, a new algorithm was developed for use with the large-scale atomic/molecular massively parallel simulator (LAMMPS) simulation package to study the cross-linking process; this new approach combines both a distance-based criterion and several kinetic criteria to identify whether the reaction has occurred. Using this simulation framework, we investigated the effect of model size on predicted thermomechanical properties of three different structural systems: diglycidyl ether of bisphenol A (DGEBA)/4,4'-diaminodiphenyl sulfone (4,4'-DDS), DGEBA/diethylenetriamine (DETA), and tetraglycidyl diaminodiphenylmethane (TGDDM)/4,4'-DDS. Derived values of gel point, volume shrinkage, and cross-linked resin density were found to be insensitive to model size in these three systems. Other thermomechanical properties, i.e., glass-transition temperature, Young's modulus, and yield stress, were found to reach stable values for systems larger than ∼40 000 atoms for both DGEBA/4,4'-DDS and DGEBA/DETA. However, these same properties modeled for TGDDM/4,4'-DDS did not stabilize until the system size reached 50 000 atoms. Our results provide general guidelines for simulation system size and procedures to more accurately predict the thermomechanical properties of epoxy resins.

Impact of Blood Pressure Cuff Overinflation on Blood Pressure Measurements in Adults

Purpose: The purpose of this study is to determine effects of cuff overinflation on blood pressure (BP) measurements compared with the standardized 20 mm Hg above the loss of Korotkoff sounds when taking manual BP in adults. Methods: One hundred twelve participants were recruited. American Heart Association standard procedure guidelines were referenced. Baseline BP was measured using standard cuff inflation of 20 mm Hg above loss of systolic Korotkoff sounds, followed by BP measurements with cuff inflations of 40, 60, and 80 mm Hg above the loss of Korotkoff sounds. Results: Friedman's analysis of variance found statistically significant differences in systolic measurements between standard and all 3 over-inflation methods (P = .015). Post-hoc Wilcoxon signed-rank tests demonstrated significant difference in systolic measurements between standard cuff inflation and 60 and 80 mm Hg above the loss of Korotkoff sounds (P = .005, .003). Conclusions: This study reveals blood pressure cuff inflation 60 mm Hg past the loss of Korotkoff sounds creates statistically significant differences in systolic BP measurements as compared with recommended procedures. Higher cuff inflation levels may significantly change BP measurements and decrease accuracy of clinical decision-making and medical management.

Planning neurosurgical interventions in patients with anticoagulant therapy

Clinical practice guideline on anticoagulation is intended to manage patients undergoing neurosurgical procedures for the best possible short and long-term outcomes. In the clinical office practice, anticoagulation is offered to prevent thromboembolism with Warfarin, Heparin, Novel Oral Anticoagulants. The management approach starts with the mitigation plans from a reversal of pre-procedural anticoagulants for impending neurosurgical procedures by estimating procedural bleeding risk on the patients. The haemorrhage criteria and the timing of procedures are best assessed by the proceduralist during and after the intervention, standing on ground situations. Yet, intra- and post-procedure anticoagulant therapy should induct a multidisciplinary consultation paradigm for the best outcome in any emergent scenario. Further, each anticoagulation event should be monitored closely with competence in the optimum reversal process. Different neurosurgical procedures also should be weighed for their inherent hazards along with the probabilities of the bleeding and thromboembolism. The treating team should also concur to suggest a resumption of the pre-procedure anticoagulant therapy which may have been in place for altogether different morbidities. Regarding the anticoagulant agent, there are special conditions and recommendations to bear in mind in the daily medical practice for patient management. In the clinical practice guidelines for neurosurgical procedures, decisions about initiation and continuation of anticoagulants require experience and thorough internalization of the planned procedure, to avoid the risks of inherent risks of bleeding and thromboembolism.

Clinical Practice Guidelines for Pre-Analytical Procedures of Plasma Epidermal Growth Factor Receptor Variant Testing.

Standardization of cell-free DNA (cfDNA) testing processes is necessary to obtain clinically reliable results. The pre-analytical phase of cfDNA testing greatly influences the results because of the low proportion and stability of circulating tumor DNA (ctDNA). In this review, we provide evidence-based clinical practice guidelines for pre-analytical phase procedures of plasma epidermal growth factor receptor gene (EGFR) variant testing. Specific recommendations for pre-analytical procedures were proposed based on evidence from the literature and our experimental data. Standardization of pre-analytical procedures can improve the analytical performance of cfDNA testing.

EANM procedure guideline for the treatment of liver cancer and liver metastases with intra-arterial radioactive compounds

Primary liver tumours (i.e. hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC)) are among the most frequent cancers worldwide. However, only 10–20% of patients are amenable to curative treatment, such as resection or transplant. Liver metastases are most frequently caused by colorectal cancer, which accounts for the second most cancer-related deaths in Europe. In both primary and secondary tumours, radioembolization has been shown to be a safe and effective treatment option. The vast potential of personalized dosimetry has also been shown, resulting in markedly increased response rates and overall survival. In a rapidly evolving therapeutic landscape, the role of radioembolization will be subject to changes. Therefore, the decision for radioembolization should be taken by a multidisciplinary tumour board in accordance with the current clinical guidelines. The purpose of this procedure guideline is to assist the nuclear medicine physician in treating and managing patients undergoing radioembolization treatment.PreambleThe European Association of Nuclear Medicine (EANM) is a professional non-profit medical association that facilitates communication worldwide among individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. These guidelines are intended to assist practitioners in providing appropriate nuclear medicine care for patients. They are notinflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals taking into account the unique circumstances of each case. Thus, there is no implication that an approach differing from the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set out in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines. The practice of medicine involves not only the science but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or topredict with certainty a particular response to treatment. Therefore, it should be recognised that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.

Understanding the Policy Landscape Surrounding Medical Assistance in Dying in Canada's Federal Prison System.

Medical assistance in dying (MAiD) has been legal in Canada since 2016, and the implementation of MAiD for people who are incarcerated has raised ethical and procedural concerns. In this article, we review the current Correctional Service Canada guideline on MAiD alongside a joint report by the Office of the Correctional Investigator (OCI) and the Canadian Human Rights Commission (CHRC) on aging and dying in prison. We echo concerns raised by the OCI and the CHRC about the limits of adequate end-of-life care currently provided to those in custody and offer our analysis of the procedural guideline for MAiD in prison, which we argue to be inadequate in support for patient-centered care and equality in access to health care.

Review of needle electromyography complications in thrombocytopenic cancer patients.

Needle electromyography (EMG) is understood to be a relatively safe procedure based on clinical experience. There are no evidence-based guidelines for EMG procedures in thrombocytopenic patients. The purpose of this study was to determine whether there is an increased risk of bleeding complications associated with needle EMG in patients with thrombocytopenia. This retrospective study included patients with a primary cancer and thrombocytopenia who underwent needle EMG between January 1, 2016 and October 30, 2020. Patients' medical records were reviewed for demographics; diagnoses; platelet counts within a 7-day period of EMG examination; concurrent use of anticoagulants or antiplatelet medications; number of sites sampled by needle EMG, including anatomical differentiation of paraspinal and both deep and superficial limb muscles; and associated complications not limited to bleeding within 30 days of EMG examination. The initial data search identified 198 patients with a documented diagnosis of thrombocytopenia; 124 met these criteria and were included in the study. A total of 1001 muscle sample sites were documented, with 111 sites in paraspinal muscles, 876 sites in superficial limb muscles, and 14 sites within deep limb muscles. Five patients were concurrently using therapeutic anticoagulation and 3 were using antiplatelet medications. There were no clinically significant complications, but five minor incidents were documented in the medical records within 30 days post-EMG examination. Our findings suggest that bleeding complications from standard needle EMG in oncology patients with documented thrombocytopenia are rare. Testing of high-risk muscles in this patient population appears to be safe.

Evaluation and Management: General Guidelines Applicable to Most Services

In this article, we review the following general instructions for Current Procedural Terminology (CPT®) code selection and guidelines and definitions that apply to most categories of E/M service.

Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort

Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation. We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions. Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly. We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.