Published Treatment Guidelines Research Articles

Quality of care measurement for patients with ovarian cancer in Japan.

Quality of care is important to reduce disease progression, and improve both survival and quality of life. The Japan Society of Gynecologic Oncology has published treatment guidelines to promote standardized high-quality care for ovarian cancer in Japan. We developed quality indicators based on the guideline recommendations and used them on large datasets of health service use to examine the quality of ovarian cancer care. A panel of experts developed the indicators using a modified Delphi method. Adherence to each indicator was evaluated using data from a hospital-based cancer registry of patients diagnosed in 2018. All patients receiving first-line treatment at participating facilities were included. The adherence rates were returned to participating hospitals, and reasons for nonadherence were collected. A total of 580 hospitals participated, and the study examined the care received by 6611 patients with ovarian cancer and 1879 with borderline tumors using 11 measurable quality indicators. The adherence rate ranged from 22.6% for "Estrogen replacement within 6 months of operation" to 93.5% for "Bleomycin, etoposide, and cisplatin for germ cell tumor more than Stage II." Of 580 hospitals, 184 submitted the reasons for nonadherence. The quality of ovarian cancer care should be continuously assessed to encourage the use of best practices. These indicators may be a useful tool for this purpose.

Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines.

Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication.

Adequacy of Children's Psychopharmacology Services: Variations by Race and Clinical Characteristics.

An expert consensus approach was used to determine the adequacy of children's psychopharmacology and to examine whether adequacy varied by demographic or clinical characteristics. Data were from the baseline interview of 601 children, ages 6-12 years, who had visited one of nine outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms study. Children and parents were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia and the Service Assessment for Children and Adolescents to assess the child's psychiatric symptoms and lifetime mental health services use, respectively. An expert consensus approach informed by published treatment guidelines was used to determine the adequacy of children's psychotropic medication treatment. Black children (compared with White children; OR=1.84, 95% CI=1.53-2.23) and those with anxiety disorders (vs. no anxiety disorder; OR=1.55, 95% CI=1.08-2.20) were more likely to receive inadequate pharmacotherapy; those whose caregivers had a bachelor's degree or more education (vs. those who had a high school education, general equivalency diploma, or less than high school education; OR=0.74, 95% CI=0.61-0.89) were less likely to receive inadequate pharmacotherapy. The consensus rater approach permitted use of published treatment efficacy data and patient characteristics (e.g., age, diagnoses, history of recent hospitalizations, and psychotherapy) to assess adequacy of pharmacotherapy. These results replicate findings of racial disparities reported in previous research using traditional methods to determine treatment adequacy (e.g., with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.

Standardizing the Diagnostic and Therapeutic Approach to Newly Diagnosed Children with ITP: Prospective Data from the ITP Consortium of North America (ICON) Quality Improvement Initiative

Background Pediatric immune thrombocytopenia (ITP) is an acquired autoimmune disorder which leads to a low platelet count and increased risk of bleeding. Despite published treatment guidelines, there is practice variation among clinicians and institutions due to the low grade of available evidence. The recommended management of newly diagnosed children at low risk of serious bleeding is observation; despite this, these patients are often treated with medication. These medications are only transiently effective with potential for side effects and excess lab monitoring as well as associated with increased costs and overuse of healthcare resources due to hospital admissions and encounters for medication-related side effects. Our objective is to report prospective data from a quality improvement (QI) project of the Pediatric ITP Consortium of North America (ICON) that was initiated in 2020 to improve consistency in clinical practice using national ITP guidelines. DESIGN/METHODS Within the ICON QI subcommittee, a standardized clinical care pathway for newly diagnosed childhood ITP was developed based on the American Society of Hematology (ASH) 2019 guidelines. Sites initially completed a retrospective analysis documenting the pre-QI pathway management of children, ages 1-16 years, diagnosed with ITP from January to December 2019. After local dissemination of the clinical care pathway, clinicians at all participating sites reviewed the pathway at the time of managing newly diagnosed children and completed a short survey documenting a modified Buchanan-Adix bleeding score and management decisions. Chart review was completed six months following ITP diagnosis to collect data regarding additional treatment or hospitalization. For retrospective data, total patients include those with available data. Results Retrospective data were collected from 7 centers for 205 patients managed for newly diagnosed ITP. In this pre-intervention cohort, 0.5% of patients (1/204) had a bleeding score documented at their initial visit. Most patients (63%,129/204) received initial medication treatment including intravenous immunoglobulin (54%), corticosteroids (9%), and anti-D/other (3%); 37% (75/204) were initially observed. In the 6 months after diagnosis, 11% (23/205) were admitted to the hospital for management of ITP. The ITP QI pathway was implemented prospectively in the care of 126 patients from 7 centers between November 2020 and July 2022. Of these patients,100% (126/126) had a bleeding score documented at their initial visit [Grade 0 (2%), Grade 1 (26%), Grade 2 (27%), Grade 3 (45%), Grade 4 (0%)]. Initial treatment included close observation in the majority (63%, 79/125) and medication treatment in 37% [corticosteroids (22%, 28/125) and IVIG/anti-D (14%, 18/125)] (Figure 1). Most patients were managed per the pathway according to their bleeding score (80%, 93/117). The most common reasons that providers deviated from the pathway were parent preference (50%, 12/24) and provider concern about bleeding risk (29%, 7/24). Of those with low level grade 3 bleeding, in whom the pathway suggested close observation, 62% (21/34) were observed and 38% of patients (13/34) were treated with medication (Figure 2). For patients with high level grade 3 bleeding, in whom the pathway suggested medication treatment, all patients except one were treated with medication. Of the 66 patients with 6 month follow up data, only 2 patients (3%, 2/66) were admitted to the hospital. DISCUSSION For children with newly diagnosed ITP and a platelet count <20 x 109/L who have no or mild bleeding, ASH guidelines suggest observation rather than treatment with corticosteroids. Implementation of an ITP clinical care pathway based on bleeding score led to an increase in the number of children observed. In contrast to the pre-intervention cohort, most patients treated with medication received corticosteroids rather than IVIG as per ASH guidelines. Despite the increase in patients managed with close observation, just 3% were admitted to the hospital within the first 6 months of diagnosis compared to 11% of the retrospective cohort. Our findings suggest that the use of a clinical care pathway based on objective assessment of bleeding symptoms increases management with close observation when indicated in the treatment of childhood ITP without a subsequent increase in hospitalization and increases adherence to national guidelines. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

35.1 Adequacy of Children’s Mental Health Services: Variations by Race and Clinical Characteristics

ObjectivesThis study utilized an expert consensus approach to determine adequacy of children’s mental health services and examined whether adequacy varied by demographic and/or clinical characteristics.MethodsData were obtained from 687 children aged 6 to 12 years old who had visited 1 of 9 outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Children and their parents were interviewed using the K-SADS and the Service Assessment for Children and Adolescents (SACA) to assess youths’ psychiatric symptoms and lifetime mental health services use, respectively. Analyses employed an expert consensus approach (informed by published treatment guidelines) to determine children’s psychotropic treatment adequacy.ResultsBlack youth (compared to White youth; OR = 2.03; 95% CI, 1.53-2.70), and those with anxiety disorders (vs no anxiety disorder; OR = 1.57; 95% CI, 1.10-2.24) were more likely to receive inadequate care. Youth whose caregivers had a bachelor’s or more advanced degree (vs GED, high school, or less education; OR = 0.71; 95% CI, 0.60-0.83) were less likely to receive inadequate care.ConclusionsUsing the consensus rater approach permitted the use of published treatment efficacy data and patient characteristics (eg, age, diagnoses, history of recent hospitalization, psychotherapy). These results replicate racial disparities found in previous research using traditional methods to determine treatment adequacy (eg, with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.EBP, BRD, DEI ObjectivesThis study utilized an expert consensus approach to determine adequacy of children’s mental health services and examined whether adequacy varied by demographic and/or clinical characteristics. This study utilized an expert consensus approach to determine adequacy of children’s mental health services and examined whether adequacy varied by demographic and/or clinical characteristics. MethodsData were obtained from 687 children aged 6 to 12 years old who had visited 1 of 9 outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Children and their parents were interviewed using the K-SADS and the Service Assessment for Children and Adolescents (SACA) to assess youths’ psychiatric symptoms and lifetime mental health services use, respectively. Analyses employed an expert consensus approach (informed by published treatment guidelines) to determine children’s psychotropic treatment adequacy. Data were obtained from 687 children aged 6 to 12 years old who had visited 1 of 9 outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Children and their parents were interviewed using the K-SADS and the Service Assessment for Children and Adolescents (SACA) to assess youths’ psychiatric symptoms and lifetime mental health services use, respectively. Analyses employed an expert consensus approach (informed by published treatment guidelines) to determine children’s psychotropic treatment adequacy. ResultsBlack youth (compared to White youth; OR = 2.03; 95% CI, 1.53-2.70), and those with anxiety disorders (vs no anxiety disorder; OR = 1.57; 95% CI, 1.10-2.24) were more likely to receive inadequate care. Youth whose caregivers had a bachelor’s or more advanced degree (vs GED, high school, or less education; OR = 0.71; 95% CI, 0.60-0.83) were less likely to receive inadequate care. Black youth (compared to White youth; OR = 2.03; 95% CI, 1.53-2.70), and those with anxiety disorders (vs no anxiety disorder; OR = 1.57; 95% CI, 1.10-2.24) were more likely to receive inadequate care. Youth whose caregivers had a bachelor’s or more advanced degree (vs GED, high school, or less education; OR = 0.71; 95% CI, 0.60-0.83) were less likely to receive inadequate care. ConclusionsUsing the consensus rater approach permitted the use of published treatment efficacy data and patient characteristics (eg, age, diagnoses, history of recent hospitalization, psychotherapy). These results replicate racial disparities found in previous research using traditional methods to determine treatment adequacy (eg, with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.EBP, BRD, DEI Using the consensus rater approach permitted the use of published treatment efficacy data and patient characteristics (eg, age, diagnoses, history of recent hospitalization, psychotherapy). These results replicate racial disparities found in previous research using traditional methods to determine treatment adequacy (eg, with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.

Non-pharmacological interventions for schizophrenia—analysis of treatment guidelines and implementation in 12 Southeast European countries

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries—Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia—included non-pharmacological interventions. The remaining three countries—Kosovo (UN Resolution), Romania, and Slovenia—have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5–11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

Guidelines for Parkinson's disease treatment: consensus from the Movement Disorders Scientific Department of the Brazilian Academy of Neurology - motor symptoms.

The treatment of Parkinson's disease (PD) is challenging, especially since it is considered highly individualized. The Brazilian Academy of Neurology has recognized the need to disseminate knowledge about the management of PD treatment, adapting the best evidence to the Brazilian reality. Thus, the main published treatment guidelines were reviewed based on the recommendations of group from the Movement Disorders Scientific Department of the Brazilian Academy of Neurology.

ISP Good Clinical Practice Recommendations for the management of Dentin Hypersensitivity.

Dentin hypersensitivity (DH) is a rising concern in clinical dentistry that causes pain and discomfort and negatively affects the quality of life of patients. Indian Society of Periodontology conducted a nationwide survey, involving 3000 dentists in December 2020, which revealed significant knowledge gaps regarding DH, viz., under-diagnosis, incorrect differential diagnosis, and treatment strategies/recommendations for the management of DH patients in daily clinical practice. The current paper has been envisioned and conceptualized to update the practicing Indian dentists regarding the so-called enigma of dentistry “Dentin Hypersensitivity,” based on the best available contemporary evidence. An expert panel was constituted comprising 30 subject experts from across the country, which after extensive literature review and group discussions formulated these recommendations. The panel advocated routine screening of all dentate patients for exposed dentin areas and DH to avoid under-diagnosis of the condition and suggested an early preventive management. Consensus guidelines/recommendations for the use of desensitizing agents (DAs) at home, including the use of herbal agents, are also provided within the backdrop of the Indian context. The guidelines recommend that active management of DH shall be accomplished by a combination of at home and in-office therapies, starting with the simplest and cost-effective home use of desensitizing toothpastes. A diagnostic decision tree and a flowchart for application in daily practice are designed to manage the patients suffering from DH or presenting with exposed dentin areas in dentition. Various treatment methods to manage DH have been discussed in the paper, including the insights from previously published treatment guidelines. Further, a novel system of classification of DH patients based on specific case definitions has been developed for the first time. Explicit charts regarding the available treatment options and the chronology of institution of the agent, for the management in different case categories of DH, have been provided for quick reference. The management strategy takes into account a decision algorithm based on hierarchy of complexity of treatment options and intends to improve the quality of life of the patient by long-term maintenance with an innovatively defined triple C's or 3Cs approach.

Local Anesthetic Systemic Toxicity during Labor, Birth, and Immediate Postpartum: Clinical Review.

Local anesthetic systemic toxicity (LAST) is a life-threatening event caused by elevated local anesthetic plasma concentration. It is often unrecognized or misdiagnosed. Peripartum women are at increased risk for toxicity due to pregnancy-related physiological changes. Rising serum drug levels can cause cellular level impairment of mitochondria and voltage-gated ion channels leading to a cascade of symptoms that can end in cardiac arrest. Local anesthetic systemic toxicity can mimic other maternal pathologies but may be considered if local anesthetics have been used. Published treatment guidelines for this event include lipid emulsion which is approved for use in pregnant women. We review LAST in the maternity care setting, published treatment protocols, management of maternity patients with toxicity, and recommendations to increase awareness among maternity care clinicians for this medical emergency.

A rapid review of the overuse of antibiotics during the COVID-19 pandemic: lessons learned and recommendations for the future

The coronavirus disease 2019 (COVID-19) pandemic has had severe implications on healthcare systems and the patients affected by this infectious disease. To improve outcomes for patients with COVID-19 and limit future antimicrobial resistance, there is continued urgency to improve our understanding of the rates and causative agents of secondary bacterial infections in patients with COVID‑19, and recognise whether antibiotics are being overused in patients prior to and following COVID-19 diagnosis. This article presents the results of a rapid review comparing reported rates of secondary bacterial infections with rates of antibiotic use in patients with COVID-19 predominantly in a hospital setting, within the context of treatment guidelines and recommendations. The review revealed rates of antibiotic use in patients with COVID-19 of 37–100%, far outweighing rates of secondary bacterial infections which were typically below 20%. There was a lack of consistent reporting of causative microorganisms of secondary infections, and the distinction between bacterially- and virally-induced sepsis was rarely made. Early in the pandemic, healthcare agencies published treatment guidelines recognising the importance of antimicrobial stewardship. However, many are yet to provide updated guidance detailing the most appropriate antibiotics to treat patients with concurrent COVID-19 and secondary bacterial infections in a way which limits the emergence of drug-resistant infections and does not negatively impact patient outcomes. Without significant improvements to the testing and reporting of causative organisms and corresponding updates to antimicrobial treatment guidelines, there is a risk of worsened clinical outcomes and increased burden on healthcare systems from antimicrobial resistance during the remainder of the COVID-19 pandemic and beyond.

Evidence-based primary care approach to treating people with COVID-19 infection to prevent life-threatening complications: A review of the evidence for practical application in a clinical setting

The NIH has published treatment guidelines for treating COVID-19 patients in the hospital. However, as of this writing, there are no established protocols for treating COVID-19 positive patients in primary care. Accordingly, this investigator has taken on the task of reviewing the medical literature to be able to propose evidence-based protocols for treating COVID-19 positive patients in primary care. The CDC is advising people to do nothing when they find out they are positive for COVID-19 unless they have symptoms. The evidence from the literature irrefutably shows COVID-19 infection evokes a massive and deadly hyperinflammatory response called the “Cytokine storm” and that Cytokine levels in the blood have a predictive value in identifying an impending Cytokine storm. With such data primary care providers can effectively lower Cytokine levels and prevent critical illness and death. Accordingly, this paper presents identification of the problem of not having standard practices in primary care for people who are positive for COVID-19 and not knowing who is at risk. Moreover, the evidence shows that knowing vitamin D levels and correcting deficiencies can go a long way in reducing Cytokine levels. Additionally, the literature review presents evidence that undeniably shows the stark possibility that many of the COVID-19 related deaths can be prevented by identifying who is at risk for the Cytokine storm and other complications and providing early treatment even before symptoms appear.

The Diminishing Importance of Primary Site Identification in Cancer of Unknown Primary: A Canadian Single-Center Experience.

BackgroundCancer of unknown primary (CUP) describes patients with metastatic disease without an identified primary tumor site. Successful diagnosis and treatment of these patients remains difficult. Published guidelines on CUP have highlighted “favorable” subtype groups. We investigated a series of CUP patients to review adherence to guidelines, and identification of primary cancers or “favorable” subtypes.MethodsPatients with histologically confirmed CUP at an academic institution from 2012 to 2018 were identified. Patient demographics, tumor presentation, diagnostic work-up and treatment information were retrospectively collected from electronic data records for descriptive analysis and compared to published clinical guidelines. The primary endpoint was the proportion of patients where the primary site was identified. Multivariable logistic regression models were used to identify factors associated with primary site identification. Kaplan-Meier survival curves were used to determine factors associated with poorer OS.ResultsThree hundred and five patients were included with a median follow-up time of 4.3 months. Primary tumor sites were identified in 109 patients (37.5%), which was most commonly lung cancer (33%). Statistical analyses did not identify any demographic or initial presentation factors associated with identifying the primary or not. More diagnostic tests did not increase the likelihood of primary site identification (P=0.44). Patients with an identified primary did not have longer OS than other patients (median 5.2 months vs. 4.7 months, P=0.47). 57 patients (18.7%) who had a defined “favorable” subtype experienced superior OS (36.6 months vs. 3.8 months; P<0.0001). Further, patients with good prognostic status who followed published treatment guidelines had longer OS (17.6 months vs. 13.2 months; P=0.04).ConclusionsCUP remains a difficult cancer to diagnose and treat. These results suggest identifying the primary has less impact than anticipated, but particular efforts to identify patients with “favorable” subtypes of CUP is important prognostically.

An International Survey of Health Care Services Available to Patients With Tourette Syndrome.

Objective: Tourette syndrome (TS) is a neuropsychiatric disorder that is highly associated with several comorbidities. Given the complex and multifaceted nature of TS, the condition is managed by a wide variety of practitioners in different disciplines. The goal of this study was to investigate health service delivery and care practices by clinicians who see TS patients across different geographic settings internationally.Methods: A comprehensive questionnaire was developed to assess clinical care resources for patients with TS and was sent to clinicians in Canada (CA), the United States (US), Europe (EU), and the United Kingdom (UK). Responses were compared quantitatively between geographic regions.Results: The majority of respondents, regardless of region, reported that fewer than 40% of their case-load are patients with tics. The accessibility of TS services varied among regions, as indicated by differences in wait times, telemedicine offerings, comorbidity management and the availability of behavioral therapies. First-line pharmacotherapy preferences varied among physicians in different geographical regions with CA respondents preferring alpha-2-adrenergic agonists and respondents from the UK and EU preferring dopamine receptor antagonists.Discussion: The results suggest that there is a scarcity of specialized TS clinics, potentially making access to services challenging, especially for patients newly diagnosed with TS. Differences in regional pharmacotherapeutic preferences are reflected in various published treatment guidelines in EU and North America. The lack of dedicated specialists and telemedicine availability, coupled with differences in comorbidity management, highlight the need for interprofessional care and holistic management to improve health care delivery to patients with TS.

Management Algorithms for Pancreatic Cystic Neoplasms.

The detection of pancreatic cystic neoplasms (PCNs) has increased owing to the advancement and widespread use of imaging modalities, resulting in differences between past and current management methods for PCNs, including intraductal papillary mucinous neoplasms (IPMNs). Therefore, clinicians should accurately diagnose and determine appropriate treatment strategies. However, previously published treatment guidelines for IPMNs present different indications for treatment. To review the current status of PCNs, including epidemiologic change, malignancy risk, and factors for treatment, and to provide the optimal management algorithms for PCNs, including IPMNs, from the clinician's point of view. Literature review of published studies and the authors' own work. The treatment of PCNs relies on the type of cyst that is present or suspected. Serous cystic neoplasms are usually benign, and observation is sufficient. However, surgical treatment is required for mucinous cystic neoplasms, and malignancy risk differs according to lesion size. Solid pseudopapillary neoplasms also require surgery. The detection of small IPMNs has been increasing, and most branch duct-type IPMNs are dormant. However, cysts 3 cm or larger or growing branch duct-type IPMNs must be carefully monitored because of the increasing risk of malignancy. Therefore, surveillance strategies should be different according to the size of the lesions. A tailored approach is needed for selecting surgery or surveillance, considering the malignancy potential of the lesion and patient-associated factors such as operative risks and life expectancy. Nomograms are valuable tools for selecting treatment methods as a customized approach for IPMNs.

Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes.

Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.

Lithium stabilization and misunderstandings: Toward understanding why lithium is underutilized.

In a recent Editorial, Malhi et al.1 stress how underutilized lithium is and the importance of rectifying this deficiency. Across published treatment guidelines for bipolar disorder, lithium is universally considered the gold standard and the recommended first line treatment for prophylaxis. So, why is it then prescribed less and less? In addition to the crucial points raised by Malhi et al.1 , we offer an explanation from decades of clinical and neuroscience research involving bipolar patients and their family members.

Antipsychotic Polypharmacy.

Physicians who treat patients with schizophrenia frequently encounter complex clinical situations not fully addressed by published treatment guidelines. Some of these situations lead to antipsychotic polypharmacy, often prescribed when clinical and social obstacles prevent access to clozapine and patients have had suboptimal responses to nonclozapine monotherapy. We offer our perspective on the place of antipsychotic polypharmacy in the current treatment guidelines for patients with schizophrenia. We summarize data on the prevalence of antipsychotic polypharmacy and describe common clinical situations in which this practice is encountered, along with the pharmacological underpinnings of this practice. We briefly review evidence on common risks of antipsychotic polypharmacy and describe the limited evidence for the possible benefits of such practice. Moreover, we take a look at alternative antipsychotic augmentation strategies that address all domains of psychosis.

Increased incidence of Susac syndrome: a case series study

BackgroundSusac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines.MethodsThis is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study.ResultsSeven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months.Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry.All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability.ConclusionsWe report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.

Guidelines for the Treatment of Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a rare form of pulmonary hypertension characterized by a progressive obliterative vasculopathy of the distal pulmonary arterial circulation that usually leads to right ventricular failure and death. Over the last 25years, more than a dozen drugs representing five drug classes have been developed and approved for the treatment of this devastating disease. Due to the small number of patients afflicted by PAH, most health care providers have little experience with its management. To address this gap in medical knowledge, treatment guidelines have been developed by professional organizations and expert committees. Over the last few years, these guidelines have been updated to address findings from recent clinical trials and ongoing experience with these drugs. This review provides an update on the most recently published treatment guidelines for pharmacologic treatment of PAH and incorporates them into a contemporary approach to the treatment of this disease.

Positioning sulphonylureas in a modern treatment algorithm for patients with type 2 diabetes: Expert opinion from a European consensus panel.

The large number of pharmacological agents available to treat type 2 diabetes (T2D) makes choosing the optimal drug for any given patient a complex task. Because newer agents offer several advantages, whether and when sulphonylureas (SUs) should still be used to treat T2D is controversial. Published treatment guidelines and recommendations should govern the general approach to diabetes management. However, expert opinions can aid in better understanding local practices and in formulating individual choices. The current consensus paper aims to provide additional guidance on the use of SUs in T2D. We summarize current local treatment guidelines in European countries, showing that SUs are still widely proposed as second-line treatment after metformin and are often ranked at the same level as newer glucose-lowering medications. Strong evidence now shows that sodium-glucose co-transporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with low hypoglycaemia risk, promote weight loss, and exert a positive impact on vascular, cardiac and renal endpoints. Thus, using SUs in place of SGLT-2is and GLP-1RAs may deprive patients of key advantages and potentially important cardiorenal benefits. In subjects with ascertained cardiovascular disease or at very high cardiovascular risk, SGLT-2is and/or GLP-1RAs should be used as part of diabetes management, in the absence of contraindications. Routine utilization of SUs as second-line agents continues to be acceptable in resource-constrained settings.