Standard Clinical Management Research Articles

Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care

Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. ClinicalTrials.gov Identifier: NCT02700009.

The mind-in-mind study: A pilot randomised controlled trial that compared modified mentalisation based treatment with supportive clinical management for patients with eating disorders without borderline personality disorder.

Mentalisation-based treatment (MBT) aims to improve reflective functioning. There is a growing evidence base outlining positive clinical outcomes for the use of MBT in eating disorder patients with co-morbid borderline personality disorder (BPD). The use of MBT has not been studied for eating disorder patients without BPD. This pilot study is an exploratory randomised controlled trial in which outcomes from MBT are compared with standard clinical management in a cohort of patients diagnosed with an eating disorder but not BPD. The main objectives were two-fold-to explore the use of MBT as a therapeutic modality and to test the acceptability and feasibility of the protocol design. Thirty-two participants were randomised to receive either MBT or standard treatment during an inpatient eating disorders program. All patients enrolled in the study were diagnosed with an eating disorder but did not meet DSM-5 criteria for BPD. On admission patients were categorised as very underweight (BMI 15.0-16.4kg/m2 ), underweight (BMI 16.5-18.4kg/m2 ) or healthy weight range (BMI ≥ 18.5-24.9kg/m2 ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5kg/m2 ) or non-weight restored (BMI < 18.5kg/m2 ). The primary outcome was the subscale score on the Reflective Functioning Questionnaire (RFQ-8). Secondary outcomes were subscale scores on the Eating Disorder Examination Questionnaire and the Depression, Anxiety and Stress Scale (DASS)-21. Participants were assessed at baseline and on discharge. Statistical significance was determined using repeated measurements analysis of variance (ANOVA). Both groups experienced improvements in eating disorder symptoms and measures of psychological well-being. Participants within the MBT group exhibited greater improvements in reflective capacity as defined by the RFQ-8 however these benefits appeared to be limited to patients who achieved weight restoration at discharge. The eligibility criteria-which excluded comorbid BPD-led to challenges in recruitment which limited the power of the study analysis. As participants with a range of different eating disorder diagnoses were included this led to complexities in estimating the treatment effect within a defined cohort. Although the small sample size must be noted as a limitation-the finding that weight restoration appears to be associated with improvements in reflective capacity in MBT would be worth exploring in a subsequent larger study. Modification of eligibility criteria and recruitment from a defined cohort may increase the efficiency of a future study.

Expert consensus on standard clinical management of neonatal hypoglycemia in China (2021).

There are many high-risk factors for neonatal hypoglycemia, and persistent severe hypoglycemia can lead to irreversible neurological damage and bring a great burden to family and society. Early standardized prevention and clinical management can effectively reduce the incidence rate of neonatal hypoglycemia and brain injury induced by hypoglycemia; however at present, there is still a lack of unified clinical management guidelines for neonatal hypoglycemia in China, and different medical institutions follow different clinical guidelines developed by other countries for the management of neonatal hypoglycemia. In order to further standardize the clinical management of neonatal hypoglycemia, this consensus is developed by the Group of Neonatology, Pediatric Society, Chinese Medical Association. This consensus provides 21 recommendations to address related clinical issues in the prevention, monitoring, and management of hypoglycemia in neonates with a gestational age of ≥35 weeks.

Effects of nurse-led multidisciplinary team management on cardiovascular hospitalization and quality of life in patients with atrial fibrillation: Randomized controlled trial

BackgroundAtrial fibrillation is globally the most common sustained cardiac arrhythmia which increases patient morbidity and mortality, dramatically influencing well-being. Despite substantial efforts, an optimal clinical pathway for chronic atrial fibrillation management has yet to be developed. In recent practice, a multidisciplinary team management has been recommended for patients with atrial fibrillation. However, experiments exploring nurse-led multidisciplinary team management in chronic atrial fibrillation management relative to standard clinical management are still sparse and limited. ObjectiveTo evaluate the effects of a nurse-led multidisciplinary team approach on cardiovascular hospitalization and death, and quality of life in patients with atrial fibrillation. DesignRandomized controlled trial. SettingThe Cardiology Department of a tertiary referral hospital in Beijing, China. ParticipantsEligible patients diagnosed with atrial fibrillation who consented. MethodsSubjects were randomly assigned into one of two Cardiology Units upon admission. Patients in the control group (n = 119) received usual care and those in the intervention group (n = 116) underwent a nurse-led multidisciplinary team approach. Follow-up lasted for 12 months. The primary endpoint was a composite of cardiovascular hospitalization and cardiovascular death. The secondary endpoint was the differences in the quality of life between the groups observed at 6 months and 12 months of follow-up, compared to the baseline data, as determined using a Chinese version of the Medical Outcome Study Short-Form 36 General Health Survey. ResultsPatients under intervention showed a fewer cardiovascular hospitalization (17 vs. 35, p = 0.006) than those receiving usual care. Discernible differences were also observed in rates of cardiovascular hospitalization between the two groups (hazard ratio: 2.115, 95% confidential interval: 1.228–3.643, log-rank = 6.746, p = 0.009). Quality of life was improved in both groups, but more so in the intervention group (scores, 588.0 ± 106.0 vs. 519.1 ± 120.7 at 6 months and 674.4 ± 53.4 vs. 584.1 ± 105.9 at 12 months; both p < 0.001). Repeated measures analysis of variance indicated that group-by-time and between-subjects effects in respect of patients’ quality of life (F = 9.310, p < 0.01; F = 29.042, p < 0.01, respectively). No relationships were found with cardiovascular death. ConclusionsNurse-led multidisciplinary team management reduces cardiovascular hospitalization and improves quality of life in patients with atrial fibrillation, suggesting that this innovative management approach should be implemented in clinical practice. Registration numberChinese Clinical Trial Registry (ChiCTR1800018851).

Human resource and governance challenges in the delivery of primary eye care: a mixed methods feasibility study in Nigeria

BackgroundTo increase access to eye care, the World Health Organization’s Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria.MethodsDesign: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization’s health system framework.ResultsA clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages.ConclusionOur study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

YouTube as a Source of Information on Blenderised Tube Feeding.

Blenderised tube feeding (BTF) has become an increasingly popular method of nutrition support for long-term tube-fed patients mostly children. This study surveyed perceptions and experiences on BTF shared on YouTube. From 71 videos analysed, attitudes towards BTF were mostly positive (91%) and included psychosocial benefits and improvements in gastrointestinal symptoms; no differences between caregivers and healthcare professionals were observed. Very few speakers (8%) felt there was a lack of support regarding use of BTF in schools and from healthcare professionals, because it is not part of the standard clinical management protocols. The most commonly used food items in blends included carrots (n = 16) and chicken (n = 11), and experiences from those who have used BTF included tips on recipes for blends, storing feeds and ensuring nutritional adequacy. Analysis of YouTube content on BTF was considerably positive and suggests that BTF is feasible and safe way to provide nutrition to tube-fed patients.

Barrett's Epithelium to Esophageal Adenocarcinoma: Is There a "Point of No Return"?

Background: Esophageal adenocarcinoma (EA) arises from Barrett’s epithelium (BE), and chronic gastroesophageal reflux disease is considered the strongest risk factor for disease progression. All BE patients undergo acid suppressive therapy, surveillance, and BE removal by surgery or endoscopic ablation, yet the incidence of EAC continues to increase. Despite the known side effects and mortality, the one-size-fits-all approach is the standard clinical management as there are no reliable methods for risk stratification.Methods: Paired-end Illumina NextSeq500 RNA sequencing was performed on total RNA extracted from 20-week intervals (0, 20, 40, and 60 W) of an in vitro BE carcinogenesis (BEC) model to construct time series global gene expression patterns (GEPs). The cells from two strategic time points (20 and 40 W) based on the GEPs were grown for another 20 weeks, with and without further acid and bile salt (ABS) stimulation, and the recurrent neoplastic cell phenotypes were evaluated.Results: Hierarchical clustering of 866 genes with ≥ twofold change in transcript levels across the four time points revealed maximum variation between the BEC20W and BEC40W cells. Enrichment analysis confirmed that the genes altered ≥ twofold during this window period associated with carcinogenesis and malignancy. Intriguingly, the BEC20W cells required further ABS exposure to gain neoplastic changes, but the BEC40W cells progressed to malignant transformation after 20 weeks even in the absence of additional ABS.Discussion: The transcriptomic gene expression patterns in the BEC model demonstrate evidence of a clear threshold in the progression of BE to malignancy. Catastrophic transcriptomic changes during a window period culminate in the commitment of the BE cells to a “point of no return,” and removal of ABS is not effective in preventing their malignant transformation. Discerning this “point of no return” during BE surveillance by tracking the GEPs has the potential to evaluate risk of BE progression and enable personalized clinical management.

Birth weight and intra-amniotic inflammatory and infection-related complications in pregnancies with preterm prelabor rupture of membranes: a retrospective cohort study

Objective To assess the association between the birth weight of newborns and microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation in pregnancies with preterm prelabor rupture of membranes. Methods A total of 528 pregnancies with preterm prelabor rupture of membranes were included in this retrospective cohort study. Transabdominal amniocentesis to determine the presence of MIAC (through culturing and molecular biology methods) and intra-amniotic inflammation (according to amniotic fluid interleukin-6 level) was performed as part of standard clinical management. Based on the presence of MIAC and/or intra-amniotic inflammation, the participants were divided into four subgroups: with intra-amniotic infection (presence of both), with sterile IAI (intra-amniotic inflammation alone), with colonization (MIAC alone), and with negative amniotic fluid (absence of both). Birth weights of newborns are expressed as percentiles derived from INTERGROWTH-21st standards for (i) newborn birth weight and (ii) estimated fetal weight. Results No differences in birth weights, expressed as percentiles derived from newborn weight standards (infection: median 52; sterile: median 54; colonization: median 50; negative amniotic fluid: median 51; p = .93) and estimated fetal weight standards (infection: median 47; sterile: median 51; colonization: median 47; negative amniotic fluid: median 53; p = .48) were found among the four subgroups. No differences in percentiles (derived from both standards) were found in the subset of participants who delivered within 72 h after rupture of membranes (newborn weight standard, p = .99; estimated fetal weight standard, p = .81). Conclusions No association was identified between the birth weight of newborns and the presence of intra-amniotic inflammatory and infection-related complications in pregnancies with preterm prelabor rupture of membranes.

Review - Nutraceuticals Can Target Asthmatic Bronchoconstriction: NADPH Oxidase-Dependent Oxidative Stress, RhoA and Calcium Dynamics.

Activation of various isoforms of NADPH oxidase contributes to the pathogenesis of asthma at multiple levels: promoting hypercontractility, hypertrophy, and proliferation of airway smooth muscle; enabling lung influx of eosinophils via VCAM-1; and mediating allergen-induced mast cell activation. Free bilirubin, which functions physiologically within cells as a feedback inhibitor of NADPH oxidase complexes, has been shown to have a favorable impact on each of these phases of asthma pathogenesis. The spirulina chromophore phycocyanobilin (PhyCB), a homolog of bilirubin’s precursor biliverdin, can mimic the inhibitory impact of biliverdin/bilirubin on NADPH oxidase activity, and spirulina’s versatile and profound anti-inflammatory activity in rodent studies suggests that PhyCB may have potential as a clinical inhibitor of NADPH oxidase. Hence, spirulina or PhyCB-enriched spirulina extracts merit clinical evaluation in asthma. Promoting biosynthesis of glutathione and increasing the expression and activity of various antioxidant enzymes – as by supplementing with N-acetylcysteine, Phase 2 inducers (eg, lipoic acid), selenium, and zinc – may also blunt the contribution of oxidative stress to asthma pathogenesis. Nitric oxide (NO) and hydrogen sulfide (H2S) work in various ways to oppose pathogenic mechanisms in asthma; supplemental citrulline and high-dose folate may aid NO synthesis, high-dose biotin may mimic and possibly potentiate NO’s activating impact on soluble guanylate cyclase, and NAC and taurine may boost H2S synthesis. The amino acid glycine has a hyperpolarizing effect on airway smooth muscle that is bronchodilatory. Insuring optimal intracellular levels of magnesium may modestly blunt the stimulatory impact of intracellular free calcium on bronchoconstriction. Nutraceutical regimens or functional foods incorporating at least several of these agents may have utility as nutraceutical adjuvants to standard clinical management of asthma.

Diagnosis and treatment of medication-related osteonecrosis of the jaws from an oncologist's perspectives

Along with the improvement of cancer treatment and the increasing use of bone-modifying agents, medication-related osteonecrosis of the jaw (MRONJ) has become more and more common, which may lead to reduce quality of life for patients and interrupt their regular tumor treatments. Being an oral condition in the maxillofacial region of patients associated with adverse side effect of certain bone-modifying agent related cancer therapies, MRONJ falls in a gray area between oncology and stomatology and can be challenging to treat and manage if standard clinical practice and care management guideline is not well established. Missed diagnosis and misdiagnosis of MRONJ become common when there is lack of elucidated diagnostic criteria and coordination in treatment planning between patient's oncologist and dentist. Patient's primary attending oncologist who initiates therapy with bone-modifying agent should be aware of MRONJ and well knowledgeable in best practices for preventing and managing MRONJ. With the focus on coordination of care in mind, an oral health assessment of the patient should be undertaken before initiating therapy and a dental treatment plan should be developed and implemented in coordination with the patient's dentist. Based on the systematic review of the 2019 "Medication-Related Osteonecrosis of the Jaw MASCC/ISOO/ASCO (Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology/American Society of Clinical Oncology) Clinical Practice Guideline", combined with clinical experience and academic research progress of related subject in recent years, from the perspective of an oncologist, the author summarizes how oncologists play a pivotal role in every step of the way from the initial cancer diagnosis, pre-cancer treatment assessment, care management during bone-modifying agent therapy, to the diagnosis, treatment, and management of MRONJ. The primary focus of the present article is to formulate optimized recommendations and provide guidance for multidisciplinary teams regarding best practices in the prevention and management of MRONJ in patients with cancer, in terms of early awareness, prevention, detection as well as implementation of effective treatment plan to improve clinical outcome and increase quality of life for the patients.

Inflammatory neuropsychiatric disorders and COVID-19 neuroinflammation

Neuropsychiatric sequalae to coronavirus disease 2019 (COVID-19) infection are beginning to emerge, like previous Spanish influenza and severe acute respiratory syndrome episodes. Streptococcal infection in paediatric patients causing obsessive compulsive disorder (PANDAS) is another recent example of an infection-based psychiatric disorder. Inflammation associated with neuropsychiatric disorders has been previously reported but there is no standard clinical management approach established. Part of the reason is that it is unclear what factors determine the specific neuronal vulnerability and the efficacy of anti-inflammatory treatment in neuroinflammation. The emerging COVID-19 data suggested that in the acute stage, widespread neuronal damage appears to be the result of abnormal and overactive immune responses and cytokine storm is associated with poor prognosis. It is still too early to know if there are long-term-specific neuronal or brain regional damages associated with COVID-19, resulting in distinct neuropsychiatric disorders. In several major psychiatric disorders where neuroinflammation is present, patients with abnormal inflammatory markers may also experience less than favourable response or treatment resistance when standard treatment is used alone. Evidence regarding the benefits of co-administered anti-inflammatory agents such as COX-2 inhibitor is encouraging in selected patients though may not benefit others. Disease-modifying therapies are increasingly being applied to neuropsychiatric diseases characterised by abnormal or hyperreactive immune responses. Adjunct anti-inflammatory treatment may benefit selected patients and is definitely an important component of clinical management in the presence of neuroinflammation.

Extracellular vesicles isolated from milk can improve gut barrier dysfunction induced by malnutrition

Malnutrition impacts approximately 50 million children worldwide and is linked to 45% of global mortality in children below the age of five. Severe acute malnutrition (SAM) is associated with intestinal barrier breakdown and epithelial atrophy. Extracellular vesicles including exosomes (EVs; 30–150 nm) can travel to distant target cells through biofluids including milk. Since milk-derived EVs are known to induce intestinal stem cell proliferation, this study aimed to examine their potential efficacy in improving malnutrition-induced atrophy of intestinal mucosa and barrier dysfunction. Mice were fed either a control (18%) or a low protein (1%) diet for 14 days to induce malnutrition. From day 10 to 14, they received either bovine milk EVs or control gavage and were sacrificed on day 15, 4 h after a Fluorescein Isothiocyanate (FITC) dose. Tissue and blood were collected for histological and epithelial barrier function analyses. Mice fed low protein diet developed intestinal villus atrophy and barrier dysfunction. Despite continued low protein diet feeding, milk EV treatment improved intestinal permeability, intestinal architecture and cellular proliferation. Our results suggest that EVs enriched from milk should be further explored as a valuable adjuvant therapy to standard clinical management of malnourished children with high risk of morbidity and mortality.

IBD 2020: Right therapy, right patient, right time - Choosing wisely: Conclusions.

IBD 2020: Right therapy, right patient, right time - Choosing wisely: Conclusions.

Leveraging the Coronavirus Disease 2019 Pandemic: Is It Time to Consider Incorporating Mobile Applications Into Standard Clinical Management of the Liver Transplantation Patient?

Over the past decade, major advancements in the development of mobile applications and telehealth monitoring systems have assisted healthcare professionals in the diagnosis and management of chronic disease. When effectively used, mobile applications can lead to higher quality care and better patient-reported outcomes.(1) Mobile applications can also improve patient self-management of chronic metabolic disease.(2) Despite these known benefits in other chronic diseases, telehealth and mobile applications have been slow to be adopted in standard clinical management of the liver transplant patient, in-part due to the complexity of chronic liver disease where there is often a need for physical examination, physical frailty assessment, support network determination and building rapport.(3).

Pulmonary rehabilitation for interstitial lung disease.

Pulmonary rehabilitation for interstitial lung disease.

Intra-Amniotic Infection and Sterile Intra-Amniotic Inflammation in Cervical Insufficiency with Prolapsed Fetal Membranes: Clinical Implications

Introduction: The aim of this study was to identify the rates of 2 phenotypes of intra-amniotic inflammation: intra-amniotic infection (with microbial invasion of the amniotic cavity [MIAC]) and sterile intra-amniotic inflammation (without MIAC), and their outcomes, among women with cervical insufficiency with prolapsed fetal membranes. Methods of Study: This is a retrospective study of women admitted to the Department of Obstetrics and Gynecology, University Hospital Hradec Kralove between January 2014 and May 2020. Transabdominal amniocentesis to evaluate intra-amniotic inflammation (amniotic fluid interleukin-6) and MIAC (culturing and molecular biology methods) was performed as part of standard clinical management. Results: In total, 37 women with cervical insufficiency and prolapsed fetal membranes were included; 11% (4/37) and 43% (16/37) of them had intra-amniotic infection and sterile intra-amniotic inflammation, respectively. In women with intra-amniotic infection and sterile intra-amniotic inflammation, we noted shorter intervals between admission and delivery (both p < 0.0001), and lower gestational age at delivery (p < 0.0001 and p = 0.004) and percentiles of birth/abortion weight (p = 0.03 and p = 0.009, respectively) than in those without intra-amniotic inflammation. Conclusions: Both phenotypes of intra-amniotic inflammation, with sterile intra-amniotic inflammation being more frequent, are associated with worse outcomes in pregnancies with cervical insufficiency with prolapsed fetal membranes.

Hypogammaglobulinemia and Infection Risk in Chronic Lymphocytic Leukemia (CLL) Patients Treated with CD19-Directed Chimeric Antigen Receptor T (CAR-T) Cells

Hypogammaglobulinemia and Infection Risk in Chronic Lymphocytic Leukemia (CLL) Patients Treated with CD19-Directed Chimeric Antigen Receptor T (CAR-T) Cells

Surgical Palliative Care-Where Are We in 2020?

The practice of surgical palliative care is not new. Dr Balfour M. M. Mount, a retired urologic surgeon is considered the father of North American Palliative Care and coined the term Palliative Care in 1975. Dr Geoffrey P. Dunn, a retired general surgeon and hospice and palliative medicine specialist along with other like minded surgical colleagues were instrumental in developing the field of surgical palliative care. Dr Olga Jonasson, championed the American Board of Surgery becoming one of the sponsoring boards of the Hospice and Palliative Medicine certifying exam. Dr Anne Mosenthal advocated for palliative care to be integrated as parallel clinical aims so espoused in the Trauma Quality and Improvement Program Palliative Care Best Practice Guidelines. Dr Mosenthal currently chairs the American College of Surgeons Committee on Surgical Palliative Care. This introductory article is a brief history about the origins of surgical palliative care and sheds light on the current landscape of surgeons integrating primary and specialty palliative care into surgical practice. The aim of this surgical palliative care symposium is to take everyday surgical problems and highlight the application and benefit of palliative care when treating surgical patients with serious illness. Integrating palliative care principles into standard clinical management is evidenced based patient-centered practice.

A Pilot Study to Test Feasibility the Effect Structured Education Program in Patients with Diabetes Kidney Disease

Background: Multidisciplinary team and education programs need to be set up for the treatment of complications related to diabetes. Purpose: We aimed to test a structured educational intervention coordinated by diabetes nurse educator to improve self-management of diabetes in people with diabetic kidney disease. Methods: Patients were randomly assigned to the control group to receive standard clinical management of diabetes with kidney disease or intervention group to receive the structured education. The primary endpoint was the change of renal function and metabolic parameters at 6th month. Results: The control of HbA1c to level of <7% was achieved in 40% and 10% in intervention and control group, respectively. The percentage of achieving low-density lipoprotein cholesterol < 100 mg/dl increased by 31.25% and 6.25% in intervention and control group, respectively. The percentage of achieving systolic blood pressure to <130 mmHg was also increased. At 6 months, 30% attained 3 targets in intervention group, whereas 10% attained 3 targets in the control group. Intervention group significantly improved urine albuminuria status, regression of macro- or microabuminuria to normoalbuminuria occurred in 31.25% and 11.25% in intervention and control group, respectively. Conclusion: Type 2 diabetes with diabetes kidney disease receiving a structure education program delivered by diabetes educator team is more likely to attain multiple treatment targets, by accepting treatment changes, and improved their self-care behaviors.

Usefulness of 18F-FDG PET/CT in Patients with Cardiac Implantable Electronic Device Suspected of Late Infection.

The presence of a cardiovascular implantable electronic device (CIED) can be burdened by complications such as late infections that are associated with significant morbidity and mortality and require immediate and effective treatment. The aim of this study was to evaluate the role of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) in patients with suspected CIED infection. Fifteen patients who performed a 18F-FDG PET/CT for suspicion of CIED infection were retrospectively analyzed; 15 patients, with CIED, that underwent 18F-FDG PET/CT for oncological reasons, were also evaluated. Visual qualitative analysis and semi-quantitative analysis were performed. All patients underwent standard clinical management regardless 18F-FDG PET/CT results. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) resulted as 90.91%, 75%, 86.67%, 90.91% and 75% respectively. Maximum standardized uptake values (SUVmax) and semi-quantitative ratio (SQR) were collected and showed differences statistically significant between CIED infected patients and those who were not. Exploratory cut-off values were derived from receiver operating characteristic (ROC) curves for SUVmax (2.56) and SQR (4.15). This study suggests the clinical usefulness of 18F-FDG PET/CT in patients with CIED infection due to its high sensitivity, repeatability and non-invasiveness. It can help the clinicians in decision making, especially in patients with doubtful clinical presentation. Future large-scale and multicentric studies should be conducted to establish precise protocols about 18F-FDG PET/CT performance.