Stepwise Management Research Articles

Congenital Curly Toes in the Pediatric Population: A Management Algorithm and Systematic Review

Purpose: This study aims to formulate a systematic management algorithm for pediatric congenital curly toes (CCTs), addressing the lack of standardized guidelines. By synthesizing the existing literature, the study evaluates CCT presentation, evaluation, treatment options, and outcomes. Methods: A systematic review on PubMed identified nine articles, involving 346 patients younger than 18 years with CCTs. Data extraction included presentation, evaluation, treatment modalities, and outcomes. Results: The analysis revealed that pediatric CCTs predominantly present in younger children. Clinical presentation often involves family concerns or referrals from primary care physicians, emphasizing the aesthetic nature of the condition. The most affected toes are the fourth (43.8%) and fifth (25%). Evaluation methods vary, with the Hamer grading scale and Satake imaging system being prominent. Nonsurgical treatments, including taping and observation, are favored for mild cases (grade 0 to 1), whereas surgical interventions, such as tendon transfer and flexor tenotomy, are reserved for moderate to severe cases (grade 2 to 3). Results indicate that conservative treatments yield varied outcomes, with surgical interventions demonstrating more favorable and permanent results, especially for Grades 2 to 3 deformities. Conclusion: This study proposes a stepwise management algorithm integrating clinical presentation, severity grading, and age-specific considerations for pediatric CCTs. The aim is to guide both nonsurgical and surgical interventions, enhancing clinical decision making for improved patient outcomes. Further research is recommended for algorithm validation.

The journey to LDL-C goal in the era of combination lipid lowering therapy and why it matters for ASCVD patients: a UK perspective

Objective We aim to explore the concept of distance and journey to goal, and consideration of these 2 elements a priori when choosing LLT. Methods Modelling of expected % LDL-C reductions was carried out on a range of hypothetical patients’ baseline LDL-C values prior to any LLT being commenced. Therapies were then added in a stepwise manner based on the pathway demonstrated in current national guidance and compared with goal achievement on a novel LLT optimization pathway implemented in Morecambe Bay NHS Trust. Results Modelling of a stepwise lipid management pathway shows that high-intensity statin monotherapy is not sufficient in most modelled baseline LDL-C scenarios to achieve guideline-recommended goals. Furthermore, ezetimibe second line may preclude 3rd line injectable prescribing and lead to “ezetimibe limbo” where the patient is now below the reimbursement threshold for injectable prescribing but still not achieving their LDL-C target. Overall goal achievement is poor across the spectrum of modelled LDL-C levels. In contrast, by following the Morecambe Bay pathway all patients on statin for the range of hypothetical baseline LDL-C levels can reach an LDL-C target of < 1.8 mmol/L. Conclusions This study identifies a therapeutic gap when following a stepwise approach highlighted by recent national guidance. Our proposal of a novel pathway highlights that the order in which drugs are added is important in the context of national reimbursement thresholds and allows LDL-C goal to be reached in a timely manner, regardless of the starting baseline LDL-C level.

Stepwise surgical management of binder syndrome with skeletal class III malocclusion in adults

Our study aimed to evaluate a stepwise treatment of class III malocclusion accompanied with flat nasal deformity, using orthodontics, orthognathic surgery, and rhinoplasty, as well as stability during long-term follow-up.In total, 27 patients with nasomaxillary hypoplasia and skeletal class III malocclusion were enrolled in this study. All patients had accepted orthodontic and orthognathic surgery, followed by rhinoplasty with costal cartilage as the second surgical procedure. Clinical results were evaluated by radiography, medical photography, questionnaire, and cephalometric analysis.All patients were satisfied with the surgical results and no serious complications occurred. During the follow-up, the patients showed well-corrected midface contour and nasal projection, and stable occlusion. The costal cartilage grafts were well fixed, without obvious absorption deformation. Lateral cephalometric analysis and overlay results showed that the postoperative point A had advanced approximately 5.20 ± 1.43 mm and the SNA angle had increased by approximately 5.59 ± 2.86°. Soft-tissue measurements showed a 14.22 ± 6.56° decrease in the facial lobe, while the nasolabial angle had increased by 16.83 ± 6.65° postoperatively.The results suggested that stepwise orthodontic-orthognathic surgery and rhinoplasty produce a predictable and stable result in long-term follow-up.

A typical case of Dermatomyositis

Dermatomyositis, a connective tissue disorder, is an idiopathic inflammatory myopathy characterized by skin manifestation. The diagnosis of dermatomyositis is based on characteristic skin rash, progressive muscle weakness, elevated serum muscle enzymes, abnormal EMG and muscle biopsy findings. Here we present an atypical case of a 68year old lady with all typical clinical findings failed to show response despite proper stepwise management.

(128) Penile Replantation in Patient with Klingsor Syndrome; Case Report and Review of Literature

Abstract Introduction Penile amputation has multiple etiologies including self-mutilation, work-related accidents, circumcision, assault motivated by jealousy, rage and feelings of betrayal and animal attacks. By far self –mutilation due to underlying psychiatric disorders (Klingsor Syndrome) are the commonest cause. Re-implantation is the gold standard for management, however it may always not be possible to achieve because of significant local ischemia, tissue damage and prolonged duration post trauma. Objective We are reporting our experience with one case of Klingsor Syndrome and its stepwise management. Methods A 31 years old male Schizophrenic patient self-mutilated his penile shaft due to fixed illusion (get rid of devil in his penis). He also attempted to remove his entire scrotum. His father brought his son with the amputated penile part put in ice. Immediate application of wet saline towel to penile stump and putting of amputated penile part into cold iced saline. Anti-tetanic serum was given together with i.v. antibiotics. Urology team, Plastic microsurgery team together with Psychiatry treating consultant all were emergently called at once. Amputated penile shaft was prepared by the microsurgeon to identify the dorsal artery, vein and nerves and marked by micro-bulldogs. Urology team started by fixation of s.p. cath and preparing, cleaning penile stump. End-to end anastomosis of the urethra was done. Next, the corporal bodies, were reattached using interrupted sutures. Dorsal vein and artery were re-anastomosed microsurgically Results Few days post-operatively skin necrosis started inspite of positive needle brick to the glans indicating healthy underlying glans. Second stage debridement of necrotic skin with later skin grafting resulted in cosmetically and functionally excellent penis regarding erectile and voiding functions Conclusions Penile amputation is a rare surgical emergency mostly found in the literature as isolated case reports. Klingsor syndrome is well known etiology for this type of penile injury and warrants psychiatric control. A multidisciplinary approach involving a urologist, micro-vascular surgeons as well as a psychiatrist ensures good outcome. Microvascular re-implantation remains the treatment of choice with the highest probability of adequate cosmetic as well as functional outcomes Disclosure No.

A new variant of gallbladder duplication mimicking a choledochal cyst: stepwise management of an unexpected surgical finding.

We present a case of previously unclassified duplicated gallbladder which posed a surgical challenge intraoperatively by mimicking a choledochal cyst. An intraoperative cholangiogram was performed followed by a simple cholecystectomy. No further dissection was performed to avoid bile duct injury and complication from the unconventional anatomy. Postoperative imaging and histology, followed by the second operation confirmed findings consistent with the duplicated gallbladder. Through this case, we have demonstrated the principles of safe cholecystectomy and the importance of a staged approach in an unanticipated encounter of anatomical uncertainty, as well as the description of a new variant of duplicated gallbladder.

Occipital condyle fracture in the pediatric population: A management algorithm and systematic review.

This study aims to develop an accessible stepwise management algorithm for pediatric presentations of occipital condyle fractures (OCFs) based on a systematic review of the published literature regarding diagnostic evaluation, treatment, and outcomes. A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric OCFs. Data extraction of clinical presentation, management strategies, imaging, and treatment outcome was performed. A total of 15 studies reporting on 38 patients aged 18 years and younger presenting with OCFs were identified. Loss of consciousness (LOC), depressed level of consciousness, neck pain, decreased neck range of motion (ROM), and cranial nerve injury were the most common presenting symptoms. Diagnostic imaging included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and functional radiographs to assess cervical stability. Treatment options varied and included soft collar, hard collar, and halo vest. All studies resulted in a complete healing of the OCF, with resolution of associated pain. The proposed treatment algorithm suggests a framework for the management of pediatric OCFs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a stepwise approach should be utilized in the management of isolated pediatric OCFs.

Theoretical Approaches Before the Adoption of Administrative Decisions in the Area of Public Administration

The article is devoted to the problem of researching theoretical approaches to the process of making managerial decisions in the field of public administration. It is noted that considering the process of making managerial decisions as an object of public management, it is emphasized that the decision-making process is multi-level. Such are the models and concepts on the basis of which decision-making can be explained, and which are multidimensional and interdisciplinary in their content. It is important to emphasize that decision-making is often perceived as a deliberative process that can be both rational and irrational, based on well-stated or only implicit assumptions Most scientific sources present a traditional linear concept of decision making, in other words, a sequence of steps is presented that helps the decision maker to make the best decision. There are many formal decision-making models, but it can be argued that the basis of managerial decision-making theories are the three most important and widely known theories of such decision-making, which emphasize the intellectual activity of decision-makers and the procedural aspect - the theory of rational complexity, the theory of incrementalism and mixed scanning theory. Touching upon the conditions and criteria of the managerial decision-making process in public administration, it is worth noting that there are many theories of decision-making, most of which have a descriptive element, that is, how decisions should be prepared, and normative guidance on how decisions should be made. Each of these approaches offers a framing mechanism and describes fundamental decision-making issues. Thus, the preparation of decisions in public administration is directly related to legislation, as they are limited and influenced by various factors and conditions, therefore absolutely objective decisions do not exist in public administration, there are only less subjective and more subjective decisions . It was concluded that management decision-making is one of the most difficult issues in the process of functioning of public administration, since management decision-making is influenced by many different factors and processes. Most of the models that explain management decision-making are descriptive and aim to emphasize the quality of information processing necessary for management decision-making. No single method of managerial decision-making can be singled out as the best, because different circumstances, different values of those who make managerial decisions, different goals or methods of managerial decision-making, and the situation in an organization or institution are different in each situation. It can be argued that rational or stepwise management decision-making methods are better in some situations, and mixed-scan management decision-making methods or a combination thereof in others.

Impact of the stepwise approach to cardiovascular disease prevention in patients with established ASCVD from the 2021 ESC Prevention Guideline

Abstract Background The European Society of Cardiology (ESC) 2021 Guidelines on Cardiovascular Disease Prevention in Clinical Practice advocate a stepwise approach for the treatment of cardiovascular (CV) risk factors to reduce CV-risk in patients with established atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to evaluate CV-risk reduction and residual risk for recurrent CV-events based on stepwise risk factor management. Methods In patients with established ASCVD in the UCC-SMART (n = 8,997) and European parts of the REACH registry (n = 18,364) receiving usual care, 10-year risk of recurrent major CV-events was calculated using the SMART2 risk score. The effect of guideline recommended step 1 and 2 treatment options on this risk was modelled using best available evidence from meta-analyses and trials. Step 1 treatment recommendations were smoking cessation, use an antithrombotic drug, LDL cholesterol &amp;lt;1.8 mmol/L, systolic blood pressure (SBP) &amp;lt;140 to 130 mmHg, and in people with type 2 diabetes mellitus a GLP1-receptor agonist/SGLT2-inhibitor. Step 2 treatment recommendations studied were LDL cholesterol &amp;lt;1.4 mmol/L, SBP &amp;lt;130 mmHg, dual pathway inhibition, colchicine, eicosapentaenoic acid (EPA), and in people with type 2 diabetes mellitus a GLP1-receptor agonist/SGLT2-inhibitor in people with type 2 diabetes. Two scenarios were evaluated: one with perfect attainment (ideal) and one with empiric attainment rates (realistic). Results The baseline median 10-year residual CV-risk was 26% [14-41%] overall, and 20%, 27%, and 54% in the low, moderate, and pooled high and very high European risk regions, respectively. Baseline risk was lowest in patients with only coronary artery disease and highest in patients with polyvascular disease or comorbid diabetes mellitus. In the ideal scenario, CV-risk was reduced to 14% [9-22%] overall and, 11%, 15%, and 29% following step 1 and 6% [4-10], 5%, 9%, and 12% following step 2. In the realistic scenario, CV-risk was reduced to 24% [16-36%], 20%, 24, and 47% following step 1 and 10% [7-16%], 9%, 9%, and 19% following step 2. In the ideal scenario, 43%, 22% and 4% achieved a residual risk of &amp;lt;10% following step 1 and 87%, 83% and 38% following step 2 in each respective risk region. In the realistic scenario this was 7%, 1%, and 0% after step 1 and 59%, 56%, and 13% after step 2 (Figure shows the realistic scenario for the low risk region &amp; moderate risk region). Conclusion Despite the current standard of care, patients with established ASCVD remain at high residual CV-risk across all European risk regions. Step 1 treatment targets may lower this risk substantially, but only if attainment rates are higher than empirically achieved. Intensified Step 2 treatment options result in marked further reduction of residual CV-risk and should be encouraged to be considered in all patients with established ASCVD.Realistic scenario low risk regionRealistic scenario moderate risk region

Pancreatic cystic neoplasms: a comprehensive approach to diagnosis and management

Abstract Pancreatic cystic neoplasms present a complex diagnostic scenario encompassing low- and high-grade malignancies. Their prevalence varies widely, notably increasing with age, reaching 75% in individuals older than 80 years. Accurate diagnosis is crucial, as errors occur in approximately one-third of resected cysts discovered incidentally. Various imaging modalities such as computed tomography, magnetic resonance imaging, and endoscopic techniques are available to address this challenge. However, risk stratification remains problematic, with guideline inconsistencies and diagnostic accuracy varying according to cyst type. This review proposed a stepwise management approach, considering patient factors, imaging results, and specific features. This patient-centered model offers a structured framework for optimizing the care of individuals with pancreatic cystic neoplasms.

Three decadal large‐scale ecological restoration projects across the Tibetan Plateau

AbstractAveraged over 4000 m in elevation, Tibetan Plateau (TP) functions as an important ecological security barrier in China. Alpine ecosystems present a trend of overall improvement under the influence of climate change and human activities, yet there are localized deteriorations. To improve the ecological function of the TP, large‐scale ecological restoration projects (ERPs) have been carried out over the past 30 years, which could be classified into three stages, that is, Exploration (1989–2003), Rapid Growth (2004–2014), and Comprehensive Development Stage (2015−present). With a total area of 850,000 km2, the ERPs include forest protection and construction, grassland protection and construction, water and soil erosion control, and desertification land management. The positive effect at the local scale has been widely verified, but the responses of productivity and species diversity were inconsistent. The positive effect at the regional scale gradually emerges, yet the spatial heterogeneity is significant, and the quantification of driving forces is an important prerequisite. There is a significant increase of rare wild animals in natural reserves, though it failed to curb the loss of animal and plant diversity in artificially planted areas. The long‐term effects of various ERPs on biodiversity should be taken into account so as to optimize the ecological measures and build a sustainable management model after project restoration. By summarizing the above achievements and problems of ERPs, we proposed a stepwise ecological restoration and adaptive management scheme by different restoration goals and reference modes, that is, “Environmental treatment—Ecological restoration projects—Adaptive management.”

Management of Adverse Reactions for BCMA-Directed Therapy in Relapsed Multiple Myeloma: A Focused Review.

Anti-B-cell maturation antigen therapies consisting of bispecific antibodies, antibody-drug conjugates, and chimeric antigen receptor T cells have shown promising results in relapsed refractory multiple myeloma (RRMM). However, the severe side effects include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, cytopenia(s), infections, hemophagocytic lymphohistiocytosis, and organ toxicity, which could sometimes be life-threatening. This review focuses on these most common complications post-BCMA therapy. We discussed the risk factors, pathogenesis, clinical features associated with these complications, and how to prevent and treat them. We included four original studies for this focused review. All four agents (idecabtagene vicleucel, ciltacabtagene autoleucel, teclistamab, belantamab mafodotin) have received FDA approval for adult RRMM patients. We went through the FDA access data packages of the approved agents to outline stepwise management of the complications for better patient outcomes.

National Open Abdomen Audit (NOAA) - protocol for an observational audit of the use and management of the open abdomen in secondary care across Great Britain and Ireland.

Use of open abdomen (OA) remains an important life-saving manoeuvre in the management of trauma and the abdominal catastrophe. The National Open Abdomen Audit (NOAA) is an audit project investigating the indications, management, and subsequent outcomes of OA treatment throughout the UK. The aim is to generate a snapshot of practice which will inform the management of future patients and potentially reduce the significant harm that can be associated with OA. NOAA is a collaborative, prospective observational audit recruiting patients from across Great Britain and Ireland. The study will open from July 2023 with rolling recruitment across participating sites. All adult patients who leave theatre with an OA will be included and followed-up for 90 days. The primary objective is to prospectively audit the national variability in the management of the OA. Secondary outcomes include the treatment modality used for OA, indication, outcome of treatment and complications, including mortality and development of intestinal failure. All data will be recorded and managed using the secure REDCap electronic data capture and analysed using Stata (version 16.1). Results will be reported in accordance with the STROBE statement. Results will be used to formulate a practical clinical guideline on when to implement an OA along with a stepwise management plan once initiated to reduce the associated morbidity and mortality. It is hoped that participation in this study will facilitate education of surgeons with a "trickle down" effect on all members of the surgical team and remove variability in the management.

Iatrogenic perforation management using calcium silicate cement: a case report

The world today is literate enough about the basics of oral health conditions and available treatment options. Due to the availability of many resources on different platforms the urge to retain natural teeth rather than have extractions has increased. Dental catastrophes are sometimes unavoidable in everyday dental practice. The prime motive should be patient benefit while the general dental practitioner (GDP) identifies the risks associated with the case, availability of equipment and enhanced operator skill when deciding to the referral of the patient to a specialist. Most failed root canal treatment cases have one or more associated endodontic errors. This case report presents stepwise management of such a case of iatrogenic perforation that occurred during the initial endodontic management. It emphasizes the significance of evidence-based treatment planning, role of magnification, selection of the appropriate armamentarium for performing root canal treatment, use of bioactive materials that collectively demonstrate peri-apical healing following the repair of endodontic mishaps. It also emphasizes on the importance of recall in such cases where adequate healing can be tracked over a period. CPD/Clinical Relevance: Knowledge of management of iatrogenic perforations is useful information for clinicians.

ASSOCIATIONS OF INTER-ARM BLOOD PRESSURE DIFFERENCE WITH TREATMENT RESPONSE IN NEWLY TREATED HYPERTENSION

Objective: Inter-arm differences (IAD) in systolic blood pressure (SBP) predict future cardiovascular mortality and morbidity. IAD varies between measures and gets smaller with repeated measures. The relationship of IAD to response to antihypertensive treatment is unknown. We set out to examine associations of IAD with BP treatment response over 18 weeks in treatment-naïve adults with moderate to severe hypertension. Design and method: We previously reported that nurse-led accelerated stepwise management of treatment-naïve grade II/III hypertension is feasible, safe and effective, achieving control of SBP to &lt; 140 mmHg for 76% after 18 weeks. Using this cohort, univariable associations of IAD (mean of 8 simultaneous BP measurements) with vascular and clinical indices, and with BP change on treatment, were examined with mixed-effects linear regression models. Candidate univariable indices (p&lt;0.2) entered multivariable modelling. Regression modelling of change in IAD was undertaken. All analyses adjusted for age, sex and entry SBP. Results: For 52 participants (mean age 59; 42% female), mean (standard deviation: SD) entry SBP was 171 (13.9) mmHg falling, after protocol-led treatment intensification, to 131 (10.7) mmHg at 18 weeks; mean systolic IAD was 4.5 (4.2) mmHg at entry and 3.9 (4.3) mmHg at 18 weeks (p = 0.28). In final adjusted models, IAD at entry was associated with handedness, height, body mass index, smoking and absence of pedal pulses. Greater reduction of SBP from entry to 18 weeks was associated with lower entry IAD, greater SD of daytime ambulatory BP, smoking history and handedness. Adjusted change in IAD over 18 weeks was correlated with falls in SBP (Adjusted R2 = 0.56). Conclusions: These data associate greater systolic IAD with reduced response to intensive BP lowering, and correlate reduction in IAD with change in BP. Slower BP target achievement can carry prognostic implications, suggesting one possible mechanism whereby IAD might predict future mortality.

A new care pathway to optimize gestational weight gain in twin pregnancies

Maternal gestational weight gain (GWG) is an important determinant of pregnancy outcomes and may have an even greater role in twin pregnancies due to the higher rate of pregnancy complications and greater nutritional demands. However, data on the optimal week-specific GWG in twin pregnancies and interventions that should be taken in cases of inadequate GWG are limited. To determine whether a new care pathway that involves monitoring GWG using a week-specific chart along with a standardized protocol for managing cases with inadequate GWG can optimize maternal GWG in twin pregnancies. In this study, patients with twin pregnancies followed in a single tertiary center between Feb-2021 and May-2022 were exposed to the new care pathway (post-intervention group). GWG and clinical outcomes were compared with a previously described cohort of patients with twins followed in our clinic before the implementation of the new care pathway (pre-intervention group). The new care pathway targeted patients and care providers and included educational material, a newly developed BMI-group-specific GWG chart, and a stepwise management algorithm in cases of inadequate GWG. The BMI-group-specific GWG charts were divided into three zones: (1) green zone (optimal GWG, at 25th-75th centiles); (2) yellow zone (suboptimal GWG, at 5th-24th or 76th-95th centiles); and (3) gray zone (abnormal GWG, at <5th or >95th centile). The primary outcome was the overall proportion of patients achieving optimal GWG at birth. A total of 123 patients were exposed to the new care pathway and were compared with 1079 patients from the pre-intervention period. Patients in the post-intervention group were more likely to achieve optimal GWG at birth (60.2% vs. 47.7%; adjusted odds ratio [aOR] 1.91, 95%-confidence interval [CI] 1.28.2.86) and were less likely to achieve low suboptimal GWG (7.3% vs. 14.7%; aOR 0.41, 95%-CI 0.20-0.85) or any suboptimal GWG (26.8% vs. 34.8%; aOR 0.60, 95%-CI 0.39-0.93) at birth. In addition, patients in the post-intervention group were less likely to experience low-abnormal GWG anytime during gestation (18.9% vs. 29.1%, p=0.017) and were more likely to experience normal GWG throughout pregnancy (21.3% vs. 14.0%, p=0.031) or high-abnormal GWG anytime during gestation (18.0% vs. 11.1%, p=0.025), suggesting that the care pathway is more effective than the standard care in preventing patients from moving into the low-abnormal zone than the high-abnormal zone. Furthermore, the new care pathway was more effective than the standard care in correcting high-suboptimal GWG and high-abnormal GWG. Our findings suggest that the new care pathway may be effective in optimizing maternal GWG in twin gestations, which may, in turn, contribute to better clinical outcomes. This is a simple, low-cost intervention that can be easily disseminated among providers caring for patients with twin pregnancies.

Urine Leak After Partial Nephrectomy: A Rare Complication After Robot-Assisted Partial Nephrectomy

In this systematic review, we looked at the rate of urine leakage from the kidney after surgical removal of kidney tumors. Urine leak (UL) is a common post-operative complication of partial nephrectomy (PN). The reported incidence varies in the literature, and there are no well-established guidelines for management of UL after PN. The goal of this study is to report the incidence and most common management strategies for UL after PN. For our quantitative synthesis, a systematic review of articles related to UL after PN from April 2010 to April 2020 was performed using PubMed and EMBASE. 475 total records were found, of which 40 reported on post-operative UL. A total of 19,904 cases were included. The overall incidence of UL was 2.8% (554/20,140). UL was most common in open cases (5.01%), followed by laparoscopic (4.40%) and robotic (1.18%) PN. Thirty-one of the included studies reported on management technique for a total of 343 interventions. UL was most frequently managed non-operatively (46.6%). Other management strategies included cystoscopy with ureteral stent placement (39.4%), percutaneous drain placement (8.7%), and percutaneous nephrostomy tube placement (2.3%). Use of nephrectomy, open reconstruction, angioembolization, or ureteroscopic techniques was uncommon (3.1%). Our study revealed that UL is rare after robotic approach to PN. Many reported cases have been managed conservatively. A stepwise management strategy is recommended. Most of these leaks heal with time or with placement of a stent into the ureter after surgery. We found that urine leak is less common with robotic surgery versus open or laparoscopic surgery.

Perceptions on Management of Atopic Dermatitis in Children Under 2 Years by Community Pediatricians: A Focus Group Study.

Atopic dermatitis (AD) is a common skin condition and is undertreated in children under 2 years, whom there are no specific guidelines for. We sought to understand barriers to AD treatment and primary care pediatricians' (PCPs) suggested solutions. We conducted semi-structured focus groups (n = 5) with PCPs (n = 17) on how the undertreatment of AD can be addressed. Data were analyzed using an inductive qualitative approach. Participants noted that the perceived undertreatment of AD in children under 2 years could be explained by topical corticosteroid (TCS) use hesitancy, lack of caregiver adherence to PCP recommendations, and under-documentation of AD in the electronic medical record (EMR). Proposed suggestions for improving AD management included caregiver and PCP education on TCS safety; stepwise management guidelines for this age group; and EMR aids to help document and manage AD. Research is warranted to create and disseminate clinician-friendly AD management guidelines for this age group.

Stepwise treatment of uncontrolled HyperTensioN (Stepwise-HTN): Study design of a cluster randomised controlled trial in primary care

BackgroundUncontrolled hypertension is a major health problem, and a key risk factor for cardiovascular disease. Most patients are detected and managed in primary care, but approximately 50% remains uncontrolled.Our aim is to assess whether a guided stepwise work-up management strategy for patients with uncontrolled hypertension in primary care would result in better blood pressure control in these patients compared to usual care. MethodsA cluster randomised controlled trial aiming at randomizing 40 general practices to either “a protocolised stepwise work-up” or to “usual care”.Uncontrolled hypertension is defined as an office blood pressure (BP) >140/90 mmHg while being prescribed three or more antihypertensive drugs simultaneously from different therapeutic classes for three or more months in an adequate dose. In the intervention arm, patients with uncontrolled hypertension will receive the stepwise approach, consisting of (i) excluding a white coat effect, (ii) re-evaluation of lifestyle, (iii) re-evaluation of drug adherence, (iv) optimalisation of antihypertensive treatment and (v) referral if the office BP is still >140/90 mmHg. The control group receives usual care in a regular program for cardiovascular risk management.The primary outcome is the absolute difference in the mean 24-h systolic BP between intervention and control arm after 8 months. Secondary outcomes include differences in the percentage of patients achieving a controlled BP, and time to reach a controlled BP. ConclusionIf stepwise treatment of uncontrolled hypertension is proven effective, the strategy could be implemented by blending the approach to the cardiovascular risk management already applied in general practice.Trial registrationNTR7304, https://www.trialregister.nl/trial/7099

Stepwise management of COPD: What is next after bronchodilation?

Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.