Standards For Clinical Practice Guidelines Research Articles

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.

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.

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.

87 An Augmented Reality Burn Management Application to Guide Care in Austere Environments

Abstract Introduction Novel medical technologies are necessary to support virtual health in low bandwidth environments. When tele-mentoring is not possible, advanced clinical decision support tools can deliver essential medical knowledge to assist novice clinicians. These tools can fill knowledge gaps in specialty fields, like burn. We developed the Augmented Reality Burn Assist Manager (ARBAM), a novel, comprehensive augmented reality (AR)-based burn management platform to address key tasks in burn care. Methods A randomized 2x2 cross-over design was used to investigate if ARBAM could enhance a user’s ability to care for a simulated burn patient as compared to standard clinical practice guidelines (CPGs). We developed the software for use on a mixed reality, head-mounted device. Participants were clinicians with little to no burn care experience, and were asked to complete 4 key tasks, twice each, using either paper copies of the Joint Trauma System’s CPGs and supplemental worksheets first (Paper) or our AR technology. Tasks included calculating burn size (TBSA), performing medication dosage calculations (MC), managing a burn fluid resuscitation (FR), and performing a simulated escharotomy (EC). All tasks were evaluated for completion time and accuracy. Cross-over analysis of treatment effects used a two-sided, two-sample t-test or Wilcoxon Rank-Sum test as appropriate. Results Eleven participants were randomized: 5 started with Paper and 6 started with AR. Time to perform FR was statistically different (p< 0.05) with AR taking less time than Paper (4.8 vs. 7.0 mins, respectively). FR clinical performance was also better in the AR group with a mean accuracy score of 99% vs. 52% for Paper (p< 0.001). EC completion times were not clinically or statistically different. However, EC accuracy was 93% for AR compared to 55% for Paper (p< 0.001). Although not statistically different, MC performance accuracy was considerably better for AR (91%) than for Paper (66%). No differences between groups were observed for TBSA or MC completion times nor TBSA accuracy. Conclusions Compared to traditional tools, AR may enhance a clinician's ability to complete key tasks in the initial management of a burn patient. This technology may be helpful during disasters when tele-mentoring is not available. Limitations of this study include a small sample size, limited user training on the AR device, and potential carry-over effects. Therefore, generalizations cannot be made about wide-scale usage. Nonetheless, this study showed that AR may be helpful in managing lifesaving burn tasks. Applicability of Research to Practice ARBAM may enhance decision making by novice clinicians when caring for burn patients. Our data demonstrate the potential for AR-based support tools to improve burn care delivery and reduce error rates for novice clinicians, which could lead to reductions in morbidity and mortality. Future research is needed to investigate how AR technology can be used for other lifesaving interventions.

Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure.

Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.

Cannabis use among cancer survivors in 22 states: Results from the Behavioral Risk Factor Surveillance System, 2020.

This study identified factors associated with recent cannabis use and cannabis use for medical purposes among cancer survivors relative to individuals without a history of cancer. Data from the Behavioral Risk Factor Surveillance System were analyzed for the 22 states completing the optional cannabis module in 2020. Weighted multiple logistic regression was performed to explore variables associated with past 30-day cannabis use and cannabis use for medical purposes, stratified by history of cancer. Covariates included state-level cannabis policy, sociodemographic characteristics, health status indicators, and substance use. Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (7.57% vs. 10.83%). However, a higher proportion of cancer survivors reported use for medical purposes (82.23% vs. 62.58%). After adjusting for state-level policy, biological sex, age, educational attainment, self-reported race/ethnicity, home ownership, mental health status and physical health status, current smoking (odds ratio [OR], 5.14 vs. 3.74) and binge drinking (OR, 2.71 vs. 2.69) were associated with cannabis use in both groups. Characteristics associated with medical cannabis use varied for the two groups; however, daily use (20-30days; OR, 1.72 vs. 2.43) was associated with cannabis use for medical purposes in both groups after adjusting for other variables in the model. A high proportion of individuals report cannabis use for medical purposes with higher rates among cancer survivors. Findings support the urgent need for ongoing cannabis research to better understand and inform its use for medical purposes, as well as the development of high-quality standardized education materials and clinical practice guidelines.

Integrating the Basic and Clinical Sciences Throughout the Medical Curriculum: Contemplating the Why, When and How

A safe, effective clinician should have the ability to reason through any case they encounter — some of which may be unusual presentations or complex cases which may not fully match standard clinical practice guidelines. When faced with a situation that does not match a known pattern, a solid foundation in the underlying principles of the scientific basis of medicine would be needed to correctly reach the most probable diagnosis and choose the most appropriate treatment strategy. The ability to do this requires the clinician to be able to integrate relevant pieces of related knowledge from both the basic and clinical sciences. However, these two elements are often taught in a dissociated manner in medical school. This often results in students struggling to see connections between the two, and often perceiving the basic sciences as being not relevant to the practice of clinical medicine. The need for better integration of the curriculum has been recognized and many medical schools have attempted to implement an integrated curriculum to varying degrees. This article attempts to summarize the theoretical basis and available evidence supporting a fully integrated spiral curriculum as an effective model for medical curriculum development in order to train safe, effective clinicians. We also briefly discuss some challenges to this and some possible strategies to overcome them.

Sudden Onset Tic and Tic-Like Presentations in Older Adolescents and Adults.

The past 3years have seen an unprecedented increase in patients with functional tic-like behaviors (FTLB), a previously rare form of functional movement disorder (FMD) that can be mistaken for Tourette syndrome (TS). This article contrasts the patient characteristics, phenomenology, risk factors, and comorbidities of FTLB and TS to define criteria for differential diagnosis. Clinical issues, treatments, theoretical explanations, and future research questions are discussed. FTLB predominately affect females, with a later onset of movements and vocalizations that are more complex, directional, severe, debilitating, and non-suppressible compared to TS. Psychosocial stressors from the pandemic, exposure to tic-content on social media, and comorbid anxiety and depression are etiological factors. Cognitive behavioral therapies appear to be effective treatment strategies. Creation of standardized clinical practice guidelines for diagnosis and treatment of this now common FMD are recommended. Etiological explanations fit coherently within a biopsychosocial model of pathology.

Patient Reported Experience with Fatigue, a Cross Sectional Study Examining Indolent and Aggressive Lymphomas

Introduction Cancer-related fatigue (CRF) is a persistent, subjective sense of physical, emotional, or cognitive tiredness related to cancer or cancer treatment which negatively impacts functioning and quality of life (NCCN, 2015). The severity of CRF varies by lymphoma subtype, stage, and treatment received. Little information is known about patients’ experience with fatigue based on the rate of disease progression (indolent or aggressive lymphomas). This study aims to offer a unique insight into the fatigue experience of patients with indolent lymphomas compared to patients with aggressive lymphomas, using the Lymphoma Coalition (LC) 2022 Global Patient Survey (GPS) on Lymphomas and CLL. Methodology Globally, 8637 respondents comprised 7,113 patients and 1,524 caregivers from 84 countries completed the 2022 LC GPS. This analysis compared patients’ experience with fatigue in a subset of patients with aggressive lymphomas (n=2921) ('AL group') and indolent lymphomas (including CLL) (n=4573) ('IL group'). Demographics of both patient groups were used to analyze questions relating to patients’ experience of fatigue. Chi-square and p values were calculated as needed, and the statistical analyses were performed with IBM SPSS v27. Results Fatigue was the most reported symptom in both groups (IL group-67% and AL group -66%) (Table 1). While 46% of the AL group affected by fatigue as a symptom reported that their lymphoma treatment alleviated the fatigue, a lower proportion of patients in the IL group (37%) reported the same. Fatigue was also the top reported side effect for the IL group (65%) and the 2nd most reported side effect for the AL group (69%) (Table 1). When asked to rank the side effects that affected them the most, fatigue was one of the top 2 side effects, ranked 1 in both groups of patients (Table 1). Patients were asked to rate the severity of their fatigue on a scale of 1 to 10 (1 being minimal fatigue and 10 being the worst fatigue imaginable). Results indicated that a higher proportion of patients in the AL group (50%) rated the severity between 6 -10 compared to those in the IL group (42%). Conversely, a higher proportion of patients in the IL group had experienced fatigue for 2 years or more (57%) compared to the AL group (36%). These differences are statistically significant (Table 1). Regarding fatigue's effect on the quality of life, half or more patients in both groups reported that fatigue affected their ability to carry out their general and physical activities and daily housework. In addition, fatigue was shown to affect mood, social activities, and enjoyment of life (Table 1). Two-thirds of the IL group reported they had discussed their fatigue with their doctors in the last two years (from survey time), compared to half of the AL group. Over half of the patients in both groups reported that their doctors did not follow up on their fatigue (Table 1). Patients reported 'information about normal vs cancer-related fatigue and 'strategies to manage their fatigue as the top information given by their doctors, while 41% of the IL group were not provided with any information on fatigue by their doctors compared to 28% of AL group (Figure 1). Balancing time schedules was the top reported coping strategy in both groups (IL group-46% vs AL group- 42%). Exercise programs and mind-body interventions followed. Conclusion The results show that fatigue is the leading physical issue affecting the well-being of patients with indolent and aggressive lymphomas. However, some differences exist in how patients may experience fatigue in terms of fatigue severity and duration. These differences may be because aggressive and indolent lymphomas often differ in symptom presentation, severity, treatment type or whether patients communicate their fatigue with their doctor. Over 50% of all patients reported that when they expressed their fatigue to their doctor, they felt it was not addressed or followed up. Given the multifactorial nature of fatigue, there is no standard treatment, and interventions that may help improve fatigue must be explored to treat underlying causes. The data highlights that regardless of lymphoma type, fatigue needs to be recognized and treated at all stages of a patient's disease, according to standard clinical practice guidelines. Healthcare providers and patients need to improve their communication about fatigue. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Nurses’ practice and educational needs in oral care for postoperative patients with oral cancer in ICUs: a multicenter cross-sectional study

BackgroundSurgical incision, endotracheal intubation, structural changes in the oral cavity, and other factors lead to a divergence in oral care between patients after oral surgery and ordinary inpatients. High-quality oral care can reduce the incidence of incision infection and ventilator-associated pneumonia. However, there is a lack of guidelines or expert consensus on oral care after oral cancer surgery. Therefore, the aim of this study was to assess the practicing situation of nurses in the intensive care unit (ICU) for postoperative patients with oral cancer and their need for training.MethodsA multicenter cross-sectional study design was conducted in 19 ICUs of 11 tertiary hospitals from Henan province in China. Data were collected from 173 nurses and 19 head nurses online using a structured questionnaire. Mann–Whitney U and Kruskal–Wallis H tests were performed to analyze the data using SPSS (Version 25.0).ResultsSeven ICUs (36.8%) developed evaluation regulations for the oral care of postoperative patients with oral cancer, and eight ICUs (42.1%) described the operating standards. A total of 173 nurses completed the questionnaire, and the median score was 75 (68, 78). Almost all of the examined nurses (91.2%) assessed patients’ oral hygiene at a fixed time, while in 52.0% and 28.3% of nurses, the first oral care and frequency of oral care after surgery was determined based on the individual patient’s situation. More than half of the nurses (55.5%) spent approximately 5–10 min conducting oral care for patients. Physiological saline solution (82.7%), swabbing (91.9%), and oral care package with cotton ball (86.1%) were the most popular oral care mouthwash, method, and tool, respectively. Nurses sought help from senior nurses (87.3%) and doctors (83.8%), mostly to solve difficulties of oral care. Moreover, 76.9% of the nurses believed that the lack of knowledge and skills surrounding oral care was the main barrier for nurses to implement oral care. The majority of participants (69.4%) had never received continuing education or training in oral care for postoperative patients with oral cancer, and almost all (98.8%) of the respondents stated their preference to receive training in standardized oral care skills. Indications and contraindications (84.4%), tools (81.5%), and mouthwash (80.9%) of oral care were the items that the respondents were most eager to learn about. Approximately three quarters of nurses preferred scenario simulation practice as the training method.ConclusionAlthough the participants had high oral care scores for postoperative patients with oral cancer, there was great diversity in the practice. The lack of oral care knowledge was deemed the main barrier in delivering quality oral care, and the educational need was stated by almost all participants. We suggest that a standard protocol or clinical practice guidelines for oral care for postoperative patients with oral cancer should be developed, and nurses should be educated to equip them with professional knowledge and skills.

Sociodemographic and clinical factors associated with receipt of biomarker testing in patients with metastatic colorectal cancer.

Standard clinical practice and national guidelines dictate somatic testing of metastatic colorectal cancer (mCRC) tumors to guide appropriate therapy; however, previous studies suggest that not all patients are tested. The objective of this study was to investigate potential differences in testing for mCRC by demographic and clinical factors. We performed a retrospective review of de-identified patient data derived from electronic health records (EHRs) of 25,469 patients diagnosed with mCRC between the years 2013 and 2020. Our outcome was a receipt of the following tests: (a) biomarker testing (BRAF, KRAS, NRAS, MMR/MSI) and (b) next-generation sequencing (NGS). We interrogated our data using the machine-learning algorithm Classification and Regression Tree (CART), a unique approach to identifying combinations of, rather than individual demographic and clinical characteristics associated with receipt of testing. A total of 25,469 patients were identified with mCRC. Of these, 21,133 (83%) received either biomarker testing only (n= 12,485) or any testing (biomarker + NGS) (n= 8648). The proportion of patients who received any testing increased over calendar time for all age, race, and sex categories. Receipt of any testing was highest (90%) among younger and patients with better performance status, and there was no difference in receipt of any testing by race. The highest percentage of NGS testing was among those with better performance status, <70 years old, commercial or other governmental program payers, and low comorbidity burden; however, those who were Black or Hispanic had a lower prevalence of NGS testing than those who were White. Considerable variations exist in somatic biomarker testing across subgroups of the population. Identification of genomic alterations can aid in determining targeted treatment and improving clinical outcomes; therefore, equitable use of these testing strategies, particularly NGS, is necessary.

Pregnancy in Patients with Non-cirrhotic Portal Hypertension: A Literature Review.

Pregnancy in non-cirrhotic portal hypertension (NCPH) is an uncommon condition. Its management is challenging both to the obstetricians as well as to the gastroenterologists due to the lack of more extensive studies and standard clinical practice guidelines. These patients are at increased risk of portal hypertension (PTH) complications, especially variceal bleeding, and with an increased incidence of adverse maternal and fetal outcomes. Hence, a multidisciplinary approach is required for management of pregnancy in NCPH. This short review describes the different aspects of pregnancy with NCPH, emphasizing specific strategies for preventing and managing PTH from the preconceptional period to postpartum.

A multicenter study of clinical impact of variant of uncertain significance reclassification in breast, ovarian, and colorectal cancer susceptibility genes.

10512 Background: Up to 10% of all cancers are attributable to germline mutations and identifying mutation carriers is critical for cancer prevention. Clinical interpretation of genetic test results is complicated by variants of uncertain significance (VUS) with unknown impact on health, which can be clarified through reclassification. However, there is little empirical evidence regarding VUS reclassification in oncology care settings, including the prevalence and outcomes of reclassification, racial/ethnic differences, and the proportion of patients who undergo cancer preventive healthcare management as a result of VUS reclassification. Methods: Retrospective analysis of persons carrying VUS (with or without an accompanying pathogenic or likely pathogenic [P/LP] variant) in breast, ovarian, and colorectal cancer genes who underwent genetic counseling at four geographically dispersed cancer care settings (in Texas, Florida, Ohio, and New Jersey) between 2013 and 2019, and followed until 2020. Results: Among 2,715 individuals, 3,261 VUS and 313 P/LP variants were reported and 11% (300/2,715) had a P/LP in addition to VUS. In total, 8.1% of all individuals with VUS experienced reclassifications, 87.1% of which were downgraded to benign or likely benign and 12.9% were upgraded to P/LP. Reclassification rates varied significantly among cancer care settings from 4.81% to 20.19% (overall p &lt; 0.001). The reclassification pattern across genes suggests that VUS in most genes underwent reclassification at a rate proportional to their prevalence in the overall sample and occurred commonly in ATM, BRCA2, BRCA1, and CHEK2. Compared to their prevalence in the sample, reclassification rates were higher for Blacks (13.6% vs 19.0%), lower for Asians (6.3% vs 3.5%), and proportional for Whites and Hispanics. Median time to reclassification decreased steadily between 2014 and 2019 from 3.08 to 0.91 years. Overall, 11.3% of all reclassified VUS resulted in clinically actionable findings and 4.6% subsequently changed individuals’ clinical managements including prophylactic surgeries and intensive screenings for cancer prevention and early detection. Conclusions: In this large multisite study, VUS reclassification changed clinical management for 0.4% of all individuals. VUS reclassification may alter clinical management, has implications for precision cancer prevention, and highlights the need for standardized clinical practice guidelines and policies for returning reclassified results to patients.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on indication for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

BackgroundMost hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses’ vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.MethodsIn...

Cognitive Impairment and Associated Factors among Older Adults with Diabetes in a Suburban Primary Health Center in Thailand

Introduction: Thailand is a rapidly aging society. The percentage of older adults with diabetes has also been increasing. Since diabetes mellitus is documented as a risk factor for dementia, it is important to address cognitive impairment in older adults with diabetes. Thus, this study aimed to evaluate the prevalence and associated factors of cognitive impairment among older adults with diabetes in a suburban primary health center in Thailand. Methods: A cross-sectional study in 244 diabetic patients aged 60 years or older was conducted in a primary health care unit in Pathum Thani, Thailand. Cognitive function was assessed with the validated Thai version of the Mini-Addenbrooke’s Cognitive Examination Test. Sociodemographic and health characteristic data were obtained. Results: The prevalence of cognitive impairment was 54.5% (133 out of 244). Multivariate logistic regression disclosed that factors significantly associated with cognitive impairment were ages 70–79 years compared to ages 60–69 years (odds ratio [OR] 1.90, 95% confidence interval [CI]: 1.01–3.62, p value 0.048), ages ≥80 years compared to ages 60–69 years (OR 3.65, 95% CI: 1.19–11.24, p value 0.024), education ≤ primary school (OR 7.28, 95% CI: 3.56–14.89, p value <0.001), and medication managed by caregiver compared to self-management of medication (OR 13.40, 95% CI: 1.55–116.10, p value 0.019). Conclusion: We revealed that approximately half of older adults with diabetes had cognitive impairment. This finding strongly suggests the need to include cognitive assessment in a standard clinical practice guideline for diabetic patients and to focus more on individuals who are very old, have low education, or are unable to manage their drugs by themselves.

Standardization in Interventional Radiology

Every day in interventional radiology (IR) is different from the one before and one that follows. There are procedures performed daily and others that may occur less frequently. In addition, each of the many procedures IR offers has a unique protocol. This clinical variation and inconsistent occurrence can create a large margin for error and put patient outcomes at risk. Studies have shown that variability in healthcare delivery can potentiate error, but standardization can decrease unnecessary variables and reduce potential harm. The World Health Organization and accrediting bodies such as The Joint Commission support the use of standardized clinical practice guidelines, and they are recognizable in existing processes such as Universal Protocol and critical care pathways.

Global guidelines for emergency general surgery: systematic review and Delphi prioritization process.

BackgroundExisting emergency general surgery (EGS) guidelines rarely include evidence from low- and middle-income countries (LMICs) and may lack relevance to low-resource settings. The aim of this study was to develop global guidelines for EGS that are applicable across all hospitals and health systems.MethodsA systematic review and thematic analysis were performed to identify recommendations relating to undifferentiated EGS. Those deemed relevant across all resource settings by an international guideline development panel were included in a four-round Delphi prioritization process and are reported according to International Standards for Clinical Practice Guidelines. The final recommendations were included as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack relevant resources at present but should plan for future implementation).ResultsAfter thematic analysis of 38 guidelines with 1396 unique recommendations, 68 recommendations were included in round 1 voting (410 respondents (219 from LMICs)). The final guidelines included eight essential, one desirable, and three critically unwell patient-specific recommendations. Preoperative recommendations included guidance on timely transfers, CT scan pathways, handovers, and discussion with senior surgeons. Perioperative recommendations included surgical safety checklists and recovery room monitoring. Postoperative recommendations included early-warning scores, discharge plans, and morbidity meetings. Recommendations for critically unwell patients included prioritization for theatre, senior team supervision, and high-level postoperative care.ConclusionThis pragmatic and representative process created evidence-based global guidelines for EGS that are suitable for resource limited environments around the world.

Efficacy of anakinra on rebound of multisystem inflammatory syndrome.

Efficacy of anakinra on rebound of multisystem inflammatory syndrome.