Standard Practice Guidelines Research Articles

Diagnostic and therapeutic challenges in implementing hypertension management after kidney transplantation.

Evidence for blood pressure (BP) measurement and hypertension management in kidney transplant recipients (KTR) remains lacking. Accurate BP measurement technique is a critical component of hypertension management, and 24-h ambulatory BP monitoring remains the gold standard for diagnosis of hypertension in KTR. BP target at different periods posttransplant is uncertain, but likely higher than that in nontransplant patients given factors related to long-standing uremic milieu and kidney transplantation such as vascular calcification altering transplant renal hemodynamic and allograft perfusion and immunosuppression. Dividing BP target into immediate, early, and late posttransplant periods can guide differential diagnoses of hypertension and BP control with a target SBP less than 160 mmHg in general and BP 115-135/65-85 mmHg for adult KTR receiving pediatric kidneys during the immediate posttransplant period, 130/80 mmHg during early and late posttransplant periods. Calcium channel blockers were shown to have favorable graft outcomes. Novel antihypertensive medications for resistant and refractory hypertension and device-based therapies are limited due to KTR's ineligibility for participating in clinical trials. In KTR, BP measurement and monitoring practice should follow the standard clinical practice guideline for nontransplant patients by considering posttransplant factors and immunosuppressive state. Novel treatment options required further studies.

Prevalence and Correlates of Cannabis Use among Cancer Survivors

Abstract Background Delaware has legalized marijuana use for both medical and recreational use. This study identified factors associated with cannabis use among adults with chronic relative to individuals without a history of cancer in the First State. Methods Combined data (2020, 2021 and 2022) from the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed for Delaware. Multivariable logistic regression examined individual-level demographic, socio-economic, clinical, and behavioral predictors associated with marijuana use stratified by history of cancer. Results Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (6.76% vs. 13.43%). However, a higher proportion of cancer survivors reported use for medical purposes (75.13% vs. 64.28%). Marijuana use prevalence decreased with age among cancer survivors. After adjusting for sex, age, educational attainment, self-reported race/ethnicity, mental health status and physical health status, current smoking (odds ratio [OR], 4.24 vs. 2.74) and binge drinking (OR, 2.45 vs. 1.75) were associated with cannabis use in both groups. Conclusions Adults with cancer were more likely to use marijuana. Marijuana use prevalence decreased with age. Public perceptions of marijuana is becoming more acceptable. Risk of medical conditions such as cancer increase with age. As such, older adults might also become consumers of marijuana. Clinicians should screen for marijuana use among patients and initiate open discussions with patients about the benefits and risks associated with marijuana. Key messages • Need for ongoing cannabis research to better understand and inform its use for medical purposes. • Development of high-quality standardized education materials and clinical practice guidelines for marijuana use.

Interpretation of a clinical practice guideline on the management of chronic pain associated with temporomandibular joint disorders

Temporomandibular disorders (TMD) are a heterogeneous group of diseases that affect the temporomandibular joint, chewing muscle system, dental occlusion, and even various structures throughout the body, with significant characteristics of biological-psychological-social pattern. TMD related chronic pain, as the most important clinical symptom, can result in negative emotions seriously affecting patients' quality of life and physical and mental health. Although a variety of therapies have been previously reported to treat TMD related chronic pain, there is a lack of widely recognized therapies. Professor Jason W Busse (from Michael G DeGroote National Pain Centre, McMaster University, Hamilton ON, Canada) took the lead and collaborated with multiple internationally renowned schools/hospitals of stomatology to develop an international consensus on the management of chronic pain associated with TMD, a clinical practice guideline, which took two years and was published in December 15th, 2023 in a global top journal of clinical research The British Medical Journal. This clinical practice guideline explored the comparative effectiveness of available therapies for chronic pain associated with TMD, conditionally recommended the specific intervention for different treatment or pain relief, proposed a comprehensive, agreed, and standardized clinical practice guideline. This present article describes the methodology and key elements of the clinical practice guideline to help clinicians fully understand and appropriately apply this guidance, which could provide the references for clinical practice of TMD associated chronic pain in China.

Analysis of ChatGPT in the Triage of Common Spinal Complaints

ChatGPT is a natural language processing chatbot with a significant prevalence in modern media with a clear application in the medical triage workflow. ChatGPT has shown significant capacity for understanding clinical vignettes, radiology reports, and even passing the American Board of Neurological Surgery board examination. There has never been an evaluation of the chatbot in triage and diagnosing spinal vignettes common to primary and urgent care practice. Fifteen clinical scenarios were created to mimic spinal complaints common to primary and urgent care scenarios. GPT-4 was instructed to assess the situation as if it was in a primary care office and determine diagnosis, imaging recommendations, and if emergency room (ER) or operative referral was necessary. Answers were recorded and the results compared to those of attending and resident respondents. GPT-4 provided the most likely diagnosis in each scenario. Additionally, it recommended reasonable clinical management of each scenario which would fall within standard practice guidelines. ChatGPT tended toward over-referral to the ER; however, this was not significant. GPT-4 was noninferior in all categories when compared to respondents. ChatGPT is a powerful tool for primary triage of spinal issues. It can rapidly and accurately evaluate clinical scenarios and provide clear diagnostic reasoning. GPT-4 is not designed for medical use and will provide a disclaimer as such. It did tend toward over-referring patients to the ER. With specific training, it is likely that artificial intelligence and natural language processing chatbots will become widely used in primary triage of spinal issues.

Rate of Diagnostic Change in Surgical Pathology Reports after Mandatory Intradepartmental Peer Review in a Tertiary Hospital in the Philippines: A Retrospective Study.

There is a mandatory intradepartmental peer review algorithm in the University of the Philippines - Philippine General Hospital (UP-PGH) Department of Laboratories wherein specific cases are required to be reviewed by another pathologist before the release of results. The main objective of this study was to determine the rate of diagnostic change in surgical pathology reports after undergoing the said review. All surgical pathology cases which underwent the review from 2015 to 2018 were retrieved from the records of the Section of Surgical Pathology. The cases were classified as concordant or discordant. A case was considered concordant if the reviewing pathologist had agreed with the primary pathologist's diagnosis. A case was considered discordant if the reviewing pathologist had disagreed with the primary pathologist's diagnosis. Out of 5,377 cases included in this study, there were 5,209 concordant cases and 168 discordant cases, with the rate of discordance computed to be 3.1%. Out of the 168 discordant cases, 107 were revised for diagnostic change. Rate of diagnostic change was computed to be 2.0% (107 out of 5,377 cases for review). The most common criterion satisfied for meriting a mandatory review is being under the category of biopsies or cytology cases with malignant or borderline diagnoses (49.4%). The most common category of diagnostic change is change in immunohistochemistry recommendations (24.3%). Most of the discordant cases and cases revised for diagnostic change fall under the categories of gastrointestinal, gynecology, and head & neck pathology. The low rate of diagnostic change in our institution might be attributed to good diagnostic accuracy. However, it is also possible that reviewing pathologists tended to agree with the diagnosis made by their colleagues because of the element of peer pressure. Data from the study may imply that special courses/ lectures or institutional standard practice guidelines on interpreting biopsy and cytology cases as well as on the utility of immunohistochemistry studies, especially those focused on gastrointestinal, gynecology, and head & neck pathology are needed by the pathologists and the doctors training to become pathologists in our institution.

Evaluation of clinical effectiveness of blood stasis leaflet in patients with blood stasis: A prospective, randomized, and crossover trial.

Blood stasis (BS) refers to a pattern of symptoms resulting from circulatory dysfunction or stagnation in the human body. Due to its historical origin and diverse interpretations, communication between patients and doctors of traditional Korean medicine (DKMs) presents challenges. Efforts to improve patients understanding in traditional Korean medicine (TKM) have led to the development of disease-specific standard clinical practice guidelines. However, there is a limited focus on creating clinical practice guidelines or informative leaflet specifically addressing BS, which is a frequently encountered pattern of symptoms in TKM. This study aimed to bridge the gap between patients and DKMs by developing an informative leaflet focusing on BS for metabolic diseases. We assessed its appropriateness through expert advisory meetings and the Delphi process, and evaluated its clinical effectiveness. We conducted a prospective, randomized, crossover trial to compare the clinical effectiveness of using BS leaflets in TKM treatment. The hypothesis investigated whether the leaflet group would show higher scores in satisfaction of DKMs' explanations, understanding of DKMs' explanations, improving the reliability of TKM, satisfaction with treatment time, improvement in explanations compared to previous TKM experiences, and necessity of managing BS treatment, compared to the no-leaflet group. In a study involving 40 patients (mean age: 62.3 ± 7.8 years), symptoms persisted for an average of 16.75 ± 9.3 hours daily, with a severity rating of 2.53. The leaflet group exhibited significantly higher satisfaction scores than the no-leaflet group in all aspects (all P < .0001). After confirming the absence of sequence and period effects using a linear-mixed effect model, we were able to ascertain the presence of a treatment effect, as evidenced by statistically significant higher scores across all survey items in the leaflet group compared to the no-leaflet group (all P < .0001). Expert consensus on symptoms aligning with the BS pattern resulted in the development of an informative leaflet. Its utilization notably improved patient satisfaction, comprehension, and trust in TKM treatment, unaffected by temporal influences, thus demonstrating its clinical effectiveness. In summary, the BS leaflet significantly enhanced patient understanding and optimized treatment procedures.

DIPG-52. CEREBROSPINAL FLUID DIVERSION DOES NOT PROLONG OVERALL SURVIVAL IN CHILDREN WITH DIFFUSE INTRINSIC PONTINE GLIOMA (DIPG): A REPORT FROM THE INTERNATIONAL DIPG REGISTRY

Abstract BACKGROUND The role of permanent cerebrospinal fluid (CSF) diversion in the management of patients with diffuse intrinsic pontine glioma (DIPG) is poorly elucidated. There are no standard practice guidelines regarding the role of these neurosurgical interventions in patients with DIPG or large studies regarding the impact of CSF diversion on overall survival (OS) or palliation in this disease. METHODS Data were extracted from subjects registered in the International DIPG registry (IDIPGR). Univariable analyses were performed using the Fisher’s exact test or Wilcoxon rank sum test. Survival was estimated using the Kaplan-Meier method. RESULTS Of n=1104 evaluable patients with DIPG registered in the IDIPGR, n=303 (27.4%) had permanent CSF diversion. Median time from diagnosis to CSF diversion was 1 month (range 0-4 months). There were no significant differences in age, gender or race in subjects with CSF diversion versus no CSF diversion. Patients with CSF diversion had a higher incidence of hydrocephalus at diagnosis (64.1% vs 11.3%, p&amp;lt;0.001). There was no significant difference in OS or post-progression survival (PPS) at 1,2 and 3 years between subjects with permanent CSF diversion compared to those without (p=0.5 and p=0.8, respectively). Median OS was 11 months in both. Median PPS was 7 months (no CSF diversion) and 6 months (CSF diversion). Patients reported less headache and vomiting after permanent CSF diversion compared to pre-diversion (p&amp;lt;0.0001), however steroid use was also significantly higher after CSF diversion (p&amp;lt;0.001). CONCLUSIONS In this, the largest reported international cohort of patients with DIPG with permanent CSF diversion, we show that permanent CSF diversion was not associated with an improvement in OS or PPS. CSF diversion improved headache and vomiting but was also associated with increased rates of steroid use. This highlights the need for consensus guidelines regarding the use of these diversion strategies in patients with DIPG.

Current perception and barriers to implementing lung ultrasound in Canadian neonatal intensive care units: a national survey.

Despite the growing body of literature supporting the use of point-of-care lung ultrasound (POC-LU) in neonates, its adoption in Canadian neonatal intensive care units (NICUs) remains limited. This study aimed to identify healthcare providers' perceptions and barriers to implementing POC-LU in Canadian NICUs. We conducted an electronic survey targeting neonatologists, neonatal fellows, neonatal nurse practitioners, and registered respiratory therapists in 20 Canadian NICUs. The survey comprised a 28-item questionnaire divided into four sections: (1) participants' demographics and availability of POC-LU equipment, (2) experience and interest in POC-LU learning, (3) perception of POC-LU as a diagnostic tool, and (4) barriers to POC-LU implementation in NICUs.A total of 194 participants completed the survey, with neonatologists comprising the majority (45%). Nearly half of the participants (48%) reported prior experience with POC-LU. The most prevalent indications for POC-LU use were diagnosis of pleural effusion (90%), pneumothorax (87%), and respiratory distress syndrome (76%). Participants identified the primary barrier to POC-LU adoption as the lack of trained providers available for both training and clinical integration. Notably, most respondents (87%) expressed keen interest in learning neonatal POC-LU. A subgroup analysis based on the responses collected from NICU-directors of 12 institutions yielded results consistent with those of the overall participant pool. Conclusion: This survey underscores the perceived importance of POC-LU among NICU healthcare providers. A Canadian consensus is required to facilitate the development of widespread training programs as well as standardized clinical practice guideline for its implementation. What is Known: • In recent years, point-of-care lung ultrasound (POC-LU) has emerged as an important tool in neonatology, revolutionizing the assessment and management of critically ill infants. However, its adoption in Canadian Neonatal Intensive Care Units remains limited. What is New: • Most Canadian healthcare providers showed high level of interest in learning POC-LU techniques. Additionally, POC-LU was perceived as a useful tool for diagnosis and guiding intervention in various neonatal respiratory diseases. Nonetheless, the lack of expertise emerged as the primary barrier to its adoption and practice across different groups of participants regardless of their clinical experience level.

Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023).

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention.

Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.

Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore.

Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play. A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus. Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF. The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Perspectives of Canadian health leaders on the relationship between medical assistance in dying and palliative and end-of-life care services: a qualitative study.

Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination. In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis. We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems). Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions.

Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones

Background and aimsSingle-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones.MethodsACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks.ResultsThe panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP.ConclusionFor adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.

Exploring the application value of the modified Delphi method in the development process of acupuncture and moxibustion guideline recommendations based on the WFAS Clinical Practice Guideline for Female Urinary Incontinence.

Taking the recommendations development of the World Federation of Acupuncture-Moxibustion Societies (WFAS) standard Clinical Practice Guideline for Female Urinary Incontinence as an example, this study analyzed the consensus expert composition, specific consensus process, and results in the development of the guideline's recommendations. It systematically examined the advantages of using the modified Delphi method in the formation of recommendations for acupuncture and moxibustion clinical practice guideline, with the aim of providing reference for the development of acupuncture and moxibustion guidelines in the same field.

Audit of Tracheostomy Care Practices in a Nigerian Tertiary Neurosurgical Intensive Care Unit According to Published Guidelines.

Chest infections are a frequently encountered problem in patients admitted to the intensive care unit (ICU), more so in tracheostomised patients. This study aimed to audit the tracheostomy care practices in patients with neurosurgical pathologies in the ICUof Wellington Clinics Abuja, a tertiary neurosurgical hospital in Nigeria. We conducted a closed-loop audit with mixed methods involving analysis of 24 patients who had tracheostomy within the first two weeks of neurosurgical pathology at a tertiary neurosurgical hospital and semi-structured interviews to determine tracheostomy care practices among the primary caregivers - nurses, intensivists, and doctors. Of the 161 ICU admissions in the first cycle, 22 patients received tracheostomy, 16 met the eligibility criteria. At re-audit (second cycle), eight of 40 patients met the criteria. All the patients received open suctioning through a dual cannula-cuffed tracheostomy tube and had independent portable suction units. In the baseline audit (first cycle), suction catheters were reused for 12-24 hours in each patient and were stored in varying combinations of normal saline and Savlon antiseptic (5 mg of cetrimide (0.5% w/w) and 1 mg of chlorhexidine digluconate (0.1% w/w)). The frequency, technique, and assessment of the need for airway suctioning were inconsistent among caregivers interviewed. All 16 patients had at least one episode of pneumonia, 10 patients had a second episode, and two patients had > two episodes. One mortality was recorded directly attributable to the complications of pneumonia. While in the re-audit, with adherence to recommendations, three patients suffered one episode of pneumonia and only one had a second episode. No mortality was recorded. A standard practice guideline wasnecessary for tracheostomy care in our ICU. In low-resource settings, stated recommendations such as single-use suction catheters and improved hygienic practices can reducerates of pneumonia in tracheostomised patients.

Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review

Background Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. Objective This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. Methods We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. Results The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40–100% worldwide. TH alters most drugs’ metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. Conclusions No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.

Optimizing Vaccine Delivery Among Pediatric Allogeneic Hematopoietic Cell Transplant Recipients: A Quality Improvement Initiative

Abstract Background Pediatric allogeneic hematopoietic cell transplantation (HCT) recipients are at risk for vaccine-preventable infections (VPI). Although evidence-based guidelines recommend starting vaccination efforts between 3-6 months post-HCT, most children remain sub-optimally vaccinated and at-risk for VPI. Our prior work demonstrated that early vaccination starting at 4-6 months post HCT was safe and immunogenic. To reduce potential patient harm from vaccine-preventable infections (VPI), we created a quality improvement (QI) initiative to increase vaccination rates among eligible pediatric allo-HCT recipients, beginning early post-HCT by implementing a best practice immunization strategy at our institution. Methods This QI initiative applied a quasi-experimental design and multiple bundled interventions in Plan-Do-Study-Act (PDSA) cycles to implement and sustain an early immunization strategy among allogeneic HCT recipients in our ambulatory HCT clinic from November 2018-May 2022. The study aimed to increase vaccination rates in eligible patients by providing a core vaccine bundle (pneumococcal conjugate [PCV13], Haemophilus influenzae type b [Hib], inactivated polio [IPV], diphtheria, tetanus, acellular pertussis [DTaP], and hepatitis B vaccines [HBV]) beginning at 6 months [Day+168 to 180] post-HCT, allowing a 30-day grace period for clinic scheduling. The number of subjects who completed a full vaccine series (4 PCV13, 3 DTaP/HBV/IPV and Hib) within the expected time post HCT were recorded. Subjects were ineligible for early vaccination if the indication for HCT was a primary immunodeficiency, and if at screening or vaccination, subjects had relapsed primary disease, graft failure, died, received anti-CD20 therapies in the preceding 6 months and had no evidence of B cell recovery, or were receiving augmented immunosuppression (prednisone-equivalent of ≥ 2 mg/kg/day). The process measure was the proportion of patients screened for vaccine eligibility vs all eligible allo-HCT recipients at 4 months post-HCT. The outcome measure included the proportion of eligible allo-HCT recipients who received the first doses of core vaccines at 6 months (+30 days) among the total number of eligible patients dur for early vaccination. PDSA interventions included creating and implementing a standardized vaccine clinical practice guideline, stakeholder engagement and communication, pre-clinic screening at 4 months post-HCT, creation of a vaccine order set per time post-HCT, and patient-individualized vaccine decision support recommendations. Results Among 72 children who underwent allo-HCT, 37 (51%) were deemed eligible for early vaccination. Review of institutional baseline data revealed that only 43% of eligible allo-HCT received the core vaccines beginning at 6 mos post-HCT. After the first two PDSA cycles, the proportion of eligible patients receiving core vaccines beginning early post-HCT increased from a baseline of 43% to 62%. After implementation of a patient-individualized vaccine decision support recommendation, early immunization rates increased to 92% and were sustained for over 2 years. In total, 33 (90%) patients, predominantly males (55%) with a median age of 9 y [range 0.33-19], received core vaccines at a median of 175 days [range 168-210] post-HCT during the study period. Among children who received early vaccination post-HCT, 82% remained eligible to continue their recommended vaccine roadmap and completed the full vaccine series by the expected 14-16 months post-HCT. Conclusions A multidisciplinary approach applying QI methodology and individualized vaccine decision support allowed for improved and sustained early vaccination after pediatric allo-HCT and completion of vaccine series, thereby reducing potential VPI-associated patient harm. Figure 1. Statistical Process Control Chart (p-chart) of Quality Improvement Initiative to Improve Vaccination Delivery Starting at 6 months After Pediatric Allogeneic Hematopoietic Cell Transplantation (HCT)

Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline

BackgroundInfants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge. MethodsWe conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007–July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts. ResultsPost-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05). ConclusionsStandardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH. Level of EvidenceIII.

Performance of Liquid Biopsy for Diagnosis and Surveillance of Human Papillomavirus–Associated Oropharyngeal Cancer

There is growing interest in the use of circulating plasma tumor human papillomavirus (HPV) DNA for diagnosis and surveillance of patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Recent advances in the assays, combining the identification of circulating HPV tumor DNA and tumor DNA fragment analysis (tumor tissue-modified viral [TTMV]-HPV DNA), have been shown to be highly accurate. However, use of these newer techniques has been limited to small cohort studies and clinical trials. To establish the clinical efficacy of plasma TTMV-HPV DNA testing in the diagnosis and surveillance of HPV-associated OPSCC in a contemporary clinical setting. This retrospective observational cohort study included patients with OPSCC who underwent TTMV-HPV DNA testing between April 2020 and September 2022 during the course of routine clinical care. For the diagnosis cohort, patients with at least 1 TTMV-HPV DNA measurement prior to initiation of primary therapy were included. Patients were included in the surveillance cohort if they had at least 1 TTMV-HPV DNA test performed after completion of definitive or salvage therapy. Per-test performance metrics, including sensitivity, specificity, positive predictive value, and negative predictive value, for TTMV-HPV DNA testing. Of 399 patients included in the analysis, 163 were in the diagnostic cohort (median [IQR] age, 63 [56-68.5] years; 142 [87.1%] male), and 290 were in the surveillance cohort (median [IQR] age, 63 [57-70] years; 237 [81.7%] male). Of the 163 patients in the diagnostic cohort, 152 (93.3%) had HPV-associated OPSCC while 11 (6.7%) had HPV-negative OPSCC. The TTMV-HPV DNA sensitivity in pretreatment diagnosis was 91.5% (95% CI, 85.8%-95.4% [139 of 152 tests]), and the specificity was 100% (95% CI, 71.5%-100% [11 of 11 tests]). In the surveillance cohort, 591 tests conducted in 290 patients were evaluated. A total of 23 patients had molecularly confirmed pathologic recurrences. The TTMV-HPV DNA test demonstrated sensitivity of 88.4% (95% CI, 74.9%-96.1% [38 of 43 tests]) and specificity of 100% (95% CI, 99.3%-100% [548 of 548 tests]) in detecting the recurrences. Positive predictive value was 100% (95% CI, 90.7%-100% [38 of 38 tests]), and negative predictive value was 99.1% (95% CI, 97.9%-99.7% [548 of 553 tests]). The median (range) lead time from positive TTMV-HPV DNA test to pathologic confirmation was 47 (0-507) days. This cohort study demonstrated that when evaluated in a clinical setting, the TTMV-HPV DNA assay demonstrated 100% specificity in both diagnosis and surveillance. However, the sensitivity was 91.5% for the diagnosis cohort and 88.4% for the surveillance cohort, signifying that nearly 1 in 10 negative tests among patients with HPV-associated OPSCC was a false negative. Additional research is required to validate the assay's performance and, if validated, then further research into the implementation of this assay into standard clinical practice guidelines will be required.

Effect of Comorbidities on Ten-Year Survival in Patients with Dementia.

There is a verified association between comorbidity and survival in patients with dementia. To describe the ten-year survival probability of patients with dementia and to identify the impact of comorbidity. The prognostic retrospective cohort study was conducted using data from adults with dementia who had visited the outpatient departments at Maharaj Nakorn Chiang Mai hospital between 2006 and 2012. Dementia was verified in accordance with standard practice guidelines. Secondary data detailing about patient age, gender, date of dementia diagnosis and death, types of dementia, and comorbidities at the time of dementia diagnosis was obtained from electronic medical records. The association between comorbidity, patients' underlying disease at dementia diagnosis, and overall survival were analyzed using a multivariable Cox proportional hazard model adjusted for age, gender, types of dementia, and other comorbidities. Of the 702 patients, 56.9% were female. Alzheimer's disease (39.6%) was the most prevalent type of dementia. Median overall survival was 6.0 years (95% CI 5.5- 6.7). The comorbidities associated with a high risk of mortality included liver disease (aHR 2.70, 95% CI 1.46- 5.00), atrial fibrillation (aHR 2.15, 95% CI 1.29- 3.58), myocardial infarction (aHR 1.55, 95% CI 1.07- 2.26), and type 2 diabetes mellitus (aHR 1.40, 95% CI 1.13- 1.74). Overall survival rate of patients with dementia in Thailand was comparable to previous studies. Several comorbidities were associated with a ten-year survival. The prognosis of patients with dementia may be improved by appropriate care of comorbidities.