Therapy In Management Of Patients Research Articles

Physical therapy for patients with low back pain in Germany: a survey of current practice

BackgroundLow back pain (LBP) is one of the most common musculoskeletal disorders worldwide. The National Disease Management Guideline (NVL) “Non-specific LBP” is a practical decision-making aid for both physicians and non-medical professionals in Germany to improve quality of health care. Although LBP is the most frequent diagnosis resulting in physical therapy treatment, information on the current management of patients with LBP and guideline adherence is limited. The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL “Non-specific LBP” recommendations.MethodsAn online survey among physical therapists working in Germany was conducted based on the recommendations given in the NVL “Non-specific LBP”. Participants were recruited using a snowball sampling approach and invited to complete the questionnaire. Guideline adherence was evaluated by comparing the survey findings with the recommendations of the NVL.ResultsIn total, 1361 physical therapists (41 years of age (SD 11); 839 female, 514 male; 16 years of clinical experience (SD 10)) completed the survey.Fifty percent (n = 675) of our respondents adhered to the recommendations of the NVL on the therapeutic diagnostic process, and 72% (n = 973) to the recommendations concerning treatment. The guideline adherence across the entire management process (i.e., both diagnosis and treatment) of LBP was 38% (n = 513). German physical therapists predominantly provide active interventions, e.g., exercise therapy, but also use interventions with low or conflicting evidence, respectively. Massage and Kinesio Taping were frequently used despite being not recommended. Less than one third of study participants (n = 400, 29%) answered to know the NVL or had dealt with its recommendations.ConclusionsIn the management of LBP, overall guideline adherence among German physical therapists was 38% with higher adherence in the treatment section than in the physical therapeutic diagnostic process. Widespread employment of implementation strategies and removal of existing barriers against the application of evidence-based guidelines could facilitate the transfer of scientific evidence into clinical practice and contribute to optimize the quality of health care.Trial registrationGerman Clinical Trials Register (DRKS00012607). Registered 04 October 2017.

Geriatric Patient with Osteoarthritis and Obesity Survived from Critically Ill of COVID-19: A Case Report

Introduction: The Corona Virus Disease (COVID-19) pandemic has become a major problem worldwide. Currently, the group of geriatrics always coincidence with chronic diseases like hypertension, diabetes mellitus, and osteoarthritis discovered with a general level of severity, disability and even death. In addition, obesity is associated with several high risks of disease severity and worse clinical outcome in COVID-19.Case: a geriatric patient with comorbidities of osteoarthritis and obesity class 1 suffered from critically ill COVID-19. Clinical manifestations that were atypical and without a history of epidemiology made it difficult to screen for COVID. Furthermore, it was found that the respiration rate, heartbeat, and blood pressure increased, oxygen saturation was only 86%, crackles all over the right lung, chest x-ray showed bilaterally infiltrates and reverse transcriptase-polymerase chain reaction (RT-PCR) test showed positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on admission. Patients managed with high flow nasal canulla (HFNC) flow 40 lpm and FiO2 78% with temperature 370C, selection of appropriate hydrophilic antibiotic such moxifloxacin iv and antiviral therapy. Obesity-related calorie regulation is given according to The Indonesian Association of Clinical Nutritionists (PDGKI), osteoarthritis medicationis still provided during the treatment resulted in a very good clinical progress. Furthermore, the patient finally recovered and was allowed to go home on the 13th day of treatment with maximum improvement.Conclusion: It is very important for clinicians to know the complex therapy management of patients in the geriatric group. This is because this population generally had atypical clinical symptoms and those that were admitted to the hospital already had severe cases.

Effectiveness of manual therapy in patients with thumb carpometacarpal osteoarthritis: a systematic review and meta-analysis

ABSTRACT Background: The effectiveness of Manual Therapy (MT) in thumb carpometacarpal osteoarthritis (OA) is unclear.Objective: This study aimed to determine the effectiveness of MT for functional outcomes in patients with thumb carpometacarpal OA. Design: Systematic review and meta-analysis of randomized clinical trials. Methods: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared MT versus other interventions in functional outcomes, such as thumb and/or hand function questionnaires, pinch and/or grip strength, thumb and/or hand range of motion, and pain intensity or pressure pain threshold in patients with thumb carpometacarpal OA. Results: Five clinical trials met the eligibility criteria; for the quantitative synthesis, four studies were included. The mean difference (MD) for grip strength was 0.87kg (95% CI = 0.29–1.44, p = .003), for pinch strength was 0.10kg (95% CI = –0.01–0.20, p = .06), and for the pressure pain threshold was 0.64kg/cm2 (95% CI = 0.07–1.20, p = .03). All differences were in favor of the MT group. Conclusions: In the short-term, there was moderate to high evidence, with statistically significant differences in the functional outcomes, in favor of MT versus sham interventions in patients with thumb carpometacarpal OA. However, these differences are not clinically important.

Role of long-term continuous cardiac monitoring in oral anticoagulation management of patients with known atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic OnBehalf Reveal LINQ Registry Investigators Background Monitoring atrial fibrillation (AF) with an insertable cardiac monitor (ICM) provides objective data for clinicians to make decisions on oral anticoagulation (OAC) management, based on individual risk profiles. Whether ICM data is being used for that purpose has not been widely explored. Purpose To show the impact of AF burden measured by an ICM on OAC treatment initiation and discontinuation in patients with known AF. Methods Patients from the prospective, ongoing, multi-center Reveal LINQ Registry monitored for AF management, or pre- or post-ablation monitoring were eligible. Follow-up was scheduled every 6 months for up to 3 years. Patients were excluded if they had no AF data available within the last 6 months of follow-up (FU), or less than 6 months of FU and no change to their OAC treatment compared to baseline. AF burden was defined as the percentage of time in AF 6 months prior to last FU, excluding the first 3 months post-ablation for patients who had an ablation. Results The analysis included 225 patients (65 ± 10 years, 72% male, mean CHA2DS2-VASc score 2.1 ± 1.4) monitored with an ICM for 21.8 ± 7.9 months. At baseline, 164 (73%) were taking OAC therapy, 147 (65%) had a history of paroxysmal AF and 79 (35%) had persistent AF. Forty percent of patients had a history of atrial ablation prior to ICM insertion and 37% had ≥1 AF ablation procedure after ICM. Patients were grouped according to OAC status at baseline, CHA2DS2-VASc score and AF burden (Figure: bars show percentage of patients with a change in OAC status during monitoring). Patients at high risk of stroke and AF burden >0.5% were more likely to initiate OAC therapy, whereas patients with higher AF burden were less likely to discontinue OAC, regardless of their risk score. Among those with no AF burden detected during the last 6 months of follow-up and on OAC at baseline, approximately half discontinued OAC, whereas 1/3 of patients with high risk score had initiated OAC, despite having no AF detected. Conclusion Our results derived from real-world practice show that AF detected and quantified by an ICM influences OAC therapy management in patients with known AF. Many patients with a low CHA2DS2-VASc score and no AF or low AF burden have had OAC therapy discontinuation, whereas a high proportion of patients with high AF burden have initiated OAC, regardless of their risk score. Abstract Figure. OAC according to risk and AF burden

Effectiveness of local exercise therapy versus spinal manual therapy in patients with patellofemoral pain syndrome: medium term follow-up results of a randomized controlled trial

BackgroundIncreasing evidence has shown benefits of spinal manipulations in patients with patellofemoral pain syndrome (PFPS). There is scarcity regarding medium term effects of spinal manual therapy on outcome measures in PFPS patients. Therefore, the aim of the present study was to compare the effectiveness of local exercise therapy and spinal manual therapy for knee pain, function and maximum voluntary peak force (MVPF) velocity of the quadriceps in PFPS patients.MethodsForty-three patients with PFPS were randomly assigned to a local exercise or spinal manual therapy group. The local exercise group received six sessions (one session per week) of supervised training of the knee-and hip muscles with mobilization of the patellofemoral joint. The spinal manual therapy group received six interventions (one intervention per week) of high velocity low thrust manipulations at the thoracolumbar region, sacroiliac joint, and/or hip. All patients were also asked to do home exercises. Maximum, minimum and current pain were measured using the visual analogue scale. Function was assessed with the anterior knee pain scale (AKPS) and MPFV was recorded using a Biodex System 3 dynamometer. Patients were assessed before intervention, after 6 weeks of intervention and after 6 weeks of follow-up. Between-group differences at assessments were analysed by way of analysis of covariance with Bonferroni correction.ResultsPain and functionality improved more following spinal manipulative therapy than local exercise therapy. After 6 weeks of intervention the between-group difference (local versus spinal) for maximal pain was 23.4 mm [95% CI: 9.3, 37.6; effect size (ES): 1.04] and − 12.4 [95% CI: − 20.2, − 4.7; ES: 1.00] for the AKPS. At 6 weeks of follow-up the between-group difference for maximal pain was 18.7 mm [95% CI: 1.4, 36.0; ES: 0.68] and − 11.5 [95% CI: − 19.9, − 3.3; ES: − 0.87] for the AKPS.ConclusionsThis study suggests that spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS in the medium term. We suggest for future research to investigate whether combining local exercise therapy and spinal manual therapy is more effective than either single intervention on its own.This clinical trial study was approved by the Medical Ethics Committee METC Z under registration number NL57207.096. and registered retrospectively in ClinicalTrials.gov PRS with registration ID number NCT04748692 on the 10th of February 2021.

Adapting Physical Therapy Management of Patients With COVID-19 in the Acute Care Setting: A Clinical Perspective

Purpose: Using emerging evidence and information pertaining to the SARS-CoV-2 virus, a team of physical therapists (PTs) and occupational therapists (OTs) at the Duke University Hospital (DUH) created a screening algorithm to guide PT/OT evaluation readiness and treatment decisions. This article aims to discuss factors that were considered in the initial development of therapy guidelines and, in so doing, emphasizes the need for ongoing analysis of such screening algorithms and treatment guidelines as evidence continues to emerge. Summary of Key Points: The interdisciplinary team, leveraging their collective experience combined with the updated literature, changed the initial medical management for patients diagnosed with coronavirus disease 2019 (COVID-19). As a result, the screening algorithm was adapted to reflect evolving evidence-based practices. This facilitated earlier and more skillful PT intervention as well as continued PT involvement in the treatment process throughout the course of the patients' stay in the hospital. Conclusions: To guide clinical decisions regarding medical stability of patients and appropriate timing for PT intervention, the therapists at DUH considered factors including defining and identifying stages of disease severity, assessment of laboratory values, and monitoring oxygen stability. Beyond medical complexity, mobility was limited by several additional isolation barriers which presented challenges for PTs, nursing staff, and the patient.

Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease.

Transcatheter aortic valve implantation (TAVI) is effective in older patients with symptomatic severe aortic stenosis, while the indication has recently broadened to younger patients at lower risk. Although thromboembolic and bleeding complications after TAVI have decreased over time, such adverse events are still common. The recommendations of the latest 2017 ESC/EACTS Guidelines for the management of valvular heart disease on antithrombotic therapy in patients undergoing TAVI are mostly based on expert opinion. Based on recent studies and randomized controlled trials, this viewpoint document provides updated therapeutic insights in antithrombotic treatment during and after TAVI.

Effectiveness of the Alfalfa App in Warfarin Therapy Management for Patients Undergoing Venous Thrombosis Prevention and Treatment: Cohort Study.

BackgroundOver the years, the internet has enabled considerable progress in the management of chronic diseases, especially hypertension and diabetes. It also provides novel opportunities in online anticoagulation management. Nevertheless, there is insufficient evidence regarding the effectiveness of online anticoagulation management.ObjectiveThis study explored the effectiveness and safety of warfarin management via the Alfalfa app, so as to provide evidence in support of anticoagulant management through online services.MethodsIn this retrospective, observational cohort study, 824 patients were included. In the offline group, patients went to the hospital clinic for warfarin management. In the Alfalfa app group, patients reported the dose of warfarin, current international normalized ratio (INR) value, and other related information through the Alfalfa app. Physicians or pharmacists used the app to adjust the dose of warfarin and determined the time for the next blood INR testing. Patients completed INR testing by point-of-care at home or hospital. The primary outcome of the study was the percentage of time in therapeutic range (TTR). Secondary outcomes included minor and major bleeding events, thrombotic events, warfarin-related emergency department visits, hospital admissions, and high INR values.ResultsThe TTR and percentage of INR values in the range were significantly higher in the Alfalfa app group than in the offline group (79.35% vs 52.38%, P<.001; 3314/4282, 77.39% vs 2005/4202, 47.72%, P<.001, respectively). Patients managed via the Alfalfa app had lower rates of subtherapeutic (172/4282, 4.02% vs 388/4202, 9.23%; P<.001), supratherapeutic (487/4282, 11.37% vs 882/4202, 20.99%; P<.001), and extreme subtherapeutic INR values (290/4282, 6.77% vs 910/4202, 21.66%; P<.001). Additionally, the Alfalfa app group had lower incidences of major bleeding (2/425, 0.5% vs 12/399, 3.0%; P=.005), warfarin-related emergency department visits (13/425, 3.1% vs 37/399, 9.3%; P<.001), and hospital admissions (1/425, 0.2% vs 12/399, 3.0%; P=.001) compared with the offline group. However, the Alfalfa app group had a higher incidence of minor bleeding than the offline group (45/425, 10.6% vs 20/399, 5.0%; P=.003). There were similar incidences in extreme supratherapeutic INR values (19/4282, 0.44% vs 17/4202, 0.40%; P=.78) and thromboembolic events (1/425, 0.2% vs 1/399, 0.3%; P=.53) between the two groups.ConclusionsWarfarin management is superior via the Alfalfa app than via offline services in terms of major bleeding events, warfarin-related emergency department visits, and hospital admissions.

Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.

Time in Therapeutic Range Using a Nomogram for Dose Adjustment of Warfarin in Patients on Hemodialysis With Atrial Fibrillation.

Background:Patients treated with hemodialysis and prescribed warfarin typically have lower time in therapeutic range (TTR) compared to the general population. This may result in less benefit or increased risk of over anticoagulation in these patients.Objective:To assess effectiveness of use of an electronic nomogram for the management of warfarin therapy in patients treated with hemodialysis.Design:Retrospective chart review.Setting:Adult patients treated with hemodialysis.Patients:Patients on hemodialysis receiving warfarin for the management of atrial fibrillation (AF) with therapy managed by nursing led electronic nomogram.Measurements:Time in therapeutic range (as fraction and Rosendaal).Methods:Retrospective chart review over 1 year of international normalized ratio (INR) results was completed, and TTR was calculated. Comparison of patients with TTR greater than 60% to those less than 60% was completed using chi-square analysis.Results:Of 43 patients with warfarin therapy managed by the nomogram, the mean TTR was 55.2% (calculated by fraction method) or 61.2% (calculated by Rosendaal method). More than half of the patients (63.5%) had moderate to good control, defined as TTR greater than 60%. Female sex, liver disease, or history of substance use and more medication holds were associated with lower TTR.Limitations:Small sample size and retrospective nature of review.Conclusions:The results of this review supports the use of an electronic, nursing-led nomogram for the maintenance management of warfarin therapy in stable patients treated with hemodialysis, as use results in TTR greater than 60% for more than half of patients.

ANTI-IL 1 Therapy in Management of Patients with Behçet’s Disease During the Covid-19 Pandemic

ANTI-IL 1 Therapy in Management of Patients with Behçet’s Disease During the Covid-19 Pandemic

Relugolix: a novel androgen deprivation therapy for management of patients with advanced prostate cancer.

Androgen deprivation therapy (ADT) is the foundation of treatment for patients with locally advanced, recurrent and metastatic prostate cancer, most commonly using luteinizing releasing hormone (LHRH) agonists. More recently, a new approach to ADT has emerged with the development of gonadotropin-releasing hormone (GnRH) antagonists, which aim to overcome some of the potential adverse physiologic effects of LHRH agonists. This article focuses on the newest GnRH antagonist, relugolix – a once-daily treatment and the only oral GnRH antagonist that has now been approved for the treatment of advanced prostate cancer. In phase II and III studies, relugolix achieved rapid and sustained castration without the testosterone surge associated with LHRH agonists, thus avoiding the potential clinical consequences of tumor flare and the necessity for concomitant anti-androgen therapy. Relugolix also achieved rapid testosterone recovery, which may potentially reduce ADT-related adverse events and offer opportunities for combination and intermittent therapy strategies. Cardiovascular safety is a particular concern in men with prostate cancer and ADT further increases cardiovascular risk: indeed, LHRH agonists are required to have a drug label warning about an increased risk of cardiovascular disease. Data from the phase III HERO study demonstrate an improved cardiac safety profile for the GnRH antagonist relugolix compared with the LHRH agonist leuprolide, including a significantly reduced risk for a major adverse cardiovascular event. Taken together, the data indicate that relugolix may mitigate some of the cardiovascular concerns surrounding ADT and has the potential to become a new standard of care for men with prostate cancer. In summary, relugolix represents a novel and recently available prostate cancer management strategy, incorporating the mechanistic advantages of GnRH antagonists and the potential benefits of oral administration.

Management of antithrombotic therapy in patients with atrial fibrillation and acute coronary syndromes.

If atrial fibrillation (AF) and acute coronary syndrome (ACS) coexist, they should be treated with combined antithrombotic therapy. To reduce the risk of bleeding while maintaining the desired antithrombotic effect, choices should be made for each patient according to the balance between the bleeding and the thrombotic risk. There are many ways to select the type and dose of the oral anticoagulant (OAC) and P2Y12 inhibitors. As a rule of thumb, aspirin and P2Y12 inhibitors should be recommended to all patients. The duration of this combination therapy is a matter of debate; available data promote an initial period of one to four weeks of triple antithrombotic association with aspirin and P2Y12 inhibitors (clopidogrel in the absence of high ischaemic risk) and preferable direct oral anticoagulants (DOACs). On discontinuing aspirin, double therapy with P2Y12 inhibitors and a DOAC provides similar efficacy and superior safety for many patients on ACS medical or interventional treatment, especially if the risk of bleeding is high and that of thrombosis is low. Further studies are needed to clarify the concerns for a slight augmentation in the number of ischaemic cases (myocardial infarction and stent thrombosis) with double antithrombotic regimen in patients at high ischaemic risk.

Comparison of manual therapy and pharmacotherapy effectiveness in the treatment and rehabilitation of patients with piriformis syndrome

Introduction . Piriformis syndrome (PFS) refers to tension of the piriformis muscle followed by compression of the sciatic nerve in the sciatic foramen. PFS occurs in 6-35 % of patients with low back pain. Such a dispersion can be explained by the difficulty in PFS diagnosing and its frequent non-detection against the background of concomitant masking pathologies. Despite the great progress in PFS research, much remains unclear. This concerns first of all the clarification of epidemiological data, risk factors and optimal treatment regimens. The widely used drug therapy does not always lead to the achievement of the required results, and it dictates the need searching for new therapy methods. Manual therapy has been successfully used for a long time in the treatment of patients with this nosology, however, most often, as an addition to the ongoing pharmacotherapy. Evaluation of the effectiveness and objectification of the manual treatment methods using as monotherapy has been little studied. The goal of research — to study the clinical effectiveness of the manual therapy and pharmacotherapy in the treatment and rehabilitation of patients with piriformis syndrome. Materials and methods . The study was conducted in 2018-2019 on the clinical basis of the Department of Sports Medicine and Medical Rehabilitation of the Federal State Autonomous Educational Institution of Higher Education I. M. First Moscow State University Sechenov (Sechenov University). The study involved 40 patients. All participants were divided into two equal groups. In the main group (group I), patients were treated with manual therapy methods, in the other group (group II), only pharmacotherapy was used. Results . The use of manual therapy in patients with piriformis syndrome leads to a significantly more pronounced decrease in the degree of pain syndrome and normalization of impaired muscle tone, in comparison with pharmacotherapy. Complications and negative reactions during treatment and after the application of methods of manual influence were not observed in all cases. Conclusion . There was a positive trend in the use of manual therapy methods for the treatment and rehabilitation of patients with piriformis syndrome in this study. It allows recommending the use of manual methods of treatment in patients with this nosology.

Factor Associated with Diabetes Burnout Syndrome Among Type 2 Diabetes Mellitus

Diabetes mellitus is a metabolic disease that is often found in Indonesia and the number of sufferers is increasing every time. Management of therapy patients with type 2 diabetes mellitus consists of five steps that require compliance and discipline to maintain stable blood sugar levels. This condition causes burnout by diabetes mellitus patients. The purpose of this study was to identify factors associated with diabetes mellitus among type 2 Diabetes mellitus. This study used a correlational design with a cross-sectional approach with a sample size of 89 respondents who were taken by purposive sampling. Based on the results of the study it was found that most Diabetes mellitus patients were 56-60 years old, female, and the education background was junior high school level. The level of income of majority of the respondents was under 1 million rupiahs and suffered from Diabetes mellitus for 1-10 years. The result found almost the entire entire patient consumed diabetes drugs. Most of the respondents had a severe category in diabetes burnout syndrome. The research found that there was a correlation between age, gender educational background, level of income, duration suffering DM, consumption of diabetes drugs with diabetes burnout syndrome among type 2 Diabetes Mellitus. Health workers must provide education about the importance of preventing the incidence of burnout syndrome and taking therapeutic management for patients who already had diabetes burnout syndrome.

Efficacy of manual therapy on somatic tinnitus dual modulatory factors: a study protocol

BACKGROUND AND PURPOSE: The literature has shown promising effect of manual therapy in improving the severity of somatic tinnitus.However, no previous study has concentrated onevaluating the combined effect of temporomandibular joint and cervical spine muscles. The purpose of the study is to evaluate the efficacy of manual therapy on somatic tinnitus dual modulatory factors (TMD and cervical spine). METHODS/DESIGN: Thirty nine patients with somatic tinnitus will be randomly assigned to one of the three groups i.e., A(Cervicogenic somatic tinnitus),B(TMJ induced somatic tinnitus) and C(Dual modulatory factors induced somatic tinnitus) respectively. This multi group, parallel arms, pre-test post-test, single centre, randomized clinical trial with three parallel groups will receive six treatment sessions of integrated manual therapy on alternate days for two weeks. Postural re-education exercises will be advised to the patients as home exercises.The primary outcome measure will be Tinnitus Handicap Inventory (THI) and secondary outcome measures include Visual Analogue Scale (VAS) and Digitalized Calibrated Algometer (DCA) to measure pre and post intervention effect of the treatments. DISCUSSION: The efficacy of manual therapy in patients with somatic tinnitus in each group will be established with this study.TRIAL REGISTRATION: Clinical Trials Registry - India. (CTRI/2020/03/024394)Universal trial number- U1111-1248-3141

Veno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic.

Rapid global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resultant clinical illness, coronavirus disease 2019 (COVID-19), drove the World Health Organization to declare COVID-19 a pandemic. Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) is an established therapy for management of patients demonstrating the most severe forms of hypoxemic respiratory failure from COVID-19. However, features of COVID-19 pathophysiology and necessary length of treatment present distinct challenges for utilization of VV-ECMO within the current healthcare emergency. In addition, growing allocation concerns due to capacity and cost present significant challenges. Ethical and legal aspects pertinent to triage of this resource-intensive, but potentially life-saving, therapy in the setting of the COVID-19 pandemic are reviewed here. Given considerations relevant to VV-ECMO use, additional emphasis has been placed on emerging hospital resource scarcity and disproportionate representation of healthcare workers among the ill. Considerations are also discussed surrounding withdrawal of VV-ECMO and the role for early communication as well as consultation from palliative care teams and local ethics committees. In discussing how to best manage these issues in the COVID-19 pandemic at present, we identify gaps in the literature and policy important to clinicians as this crisis continues.

Clinical Metrics for a Large Healthcare System’s Antimicrobial Management Program

Background: Clinical metrics and outcomes for evaluation of antimicrobial management programs (AMP) are challenging and inconsistent throughout the United States. Here, we present the results of the development of clinical metrics to measure and trend AMP outcomes within 161 acute-care facilities affiliated with a large healthcare system. Methods: Key AMP metrics were implemented in 2018 using 2017 as baseline: use of fluoroquinolones in UTIs, dosing of vancomycin, de-escalation, and intravenous (IV)-to-oral conversion of targeted drugs. Fluoroquinolone (FQ) and UTI metric evaluated all inpatients who received at least 1 dose of a FQ based on barcoded medication administration (BCMA) data and urinary tract infections were based on cystitis ICD-10 coding. Vancomycin dosing metric evaluated inpatient vancomycin troughs within therapeutic range during the admission. De-escalation metric evaluated for patients on a broad-spectrum antibiotic with a positive culture and sensitivity to narrower antibiotics. The IV-to-oral ratio was used to monitor targeted medications. Nonantimicrobial medications appropriate for IV-to- oral conversion were included in the ratio. Goals were established for each metric using the 75th percentile and ranges for “at goal,” “close to goal,” and “not at goal” were established using green–yellow–red color coding. Metrics were monitored via a systemwide dashboard that included all affiliated facilities. Data were shared monthly to key stakeholders including physicians, pharmacists, and senior leadership. Results: From 2017 to the third quarter of 2019, the FQ and UTI metric decreased 55%. This reduction in the FQ usage in UTI metric correlated with a reduction of 26.7 days of therapy (DOT) per 1,000 days present for FQ and a 50% reduction in FQ DOT for all affiliated facilities. The vancomycin dosing metric improved 2.9% from 75.2% of patients to 78.1% of patients with at least 1 vancomycin trough within range during the admission, which represents ~2,000 more patients with dosing in the target range over baseline. The de-escalation metric improved by 7% overall from 2018 to the third quarter of 2019, which translates to ~1,600 more patients with therapy de-escalated. The IV-to-oral ratio metric improved 5.5%, which means that ~180,000 more oral dosages were administered. Conclusions: Implementing AMP program clinical metrics in a large health system positively influenced antimicrobial medication therapy management for patients. Monitoring of process metrics should be considered for all AMP programs to advance antibiotic stewardship.Funding: NoneDisclosures: None

Negative pressure therapy for management of patients with enterocutaneous fistulas

Objective:To assess the benefits of negative pressure wound therapy (NPWT) in complex therapy of patients with enterocuta‑ neous fistulas.Methods: From 2014 to 2019 in Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, 24 patients were managed with vacuum assisted techniques. For comparison, a comparable group of 23 observations (control) was formed retrospectively based on an analysis of medical records.Results: When using NPWT, the terms of wound cleansing and the formation of a laparostomy were reduced, and conditions were created for its early closure. With a small laparostomy, the use of NPWT contributed to self-epithelialization of the wound around the fistula.Conclusions: The use of NPWT more than halves the time of formation of a laparostomy, shortens the time for cleansing the wound and creates the conditions for its closure. Surgical tactics using NPWT can more than three times reduce the number of local complications in patients with unformed intestinal fistulas and less often change the combination of antibacterial drugs.

Comparison of dry needling and trigger point manual therapy in patients with neck and upper back myofascial pain syndrome: a systematic review and meta-analysis

ABSTRACT Background Patients with myofascial pain syndrome of the neck and upper back have active trigger points and may present with pain and decreased function. Dry needling (DN) and trigger point manual therapy (TMPT) techniques are often used to manage MPS. Objective To compare DN and TPMT for reducing pain on the Visual Analog Scale (VAS) and Pressure Pain Threshold (PPT) scores and improving function on the Neck Disability Index (NDI) in patients with neck and upper back MPS. Methods PubMed, PEDro, and CINAHL were searched for randomized controlled trials within the last 10 years comparing a group receiving DN and the other receiving TPMT. Studies were assessed using PEDro scale and Cochrane risk-of-bias tool to assess methodological quality. Meta-analyses were performed using random-effect model. Standardized mean differences (Cohen’s d) and confidence intervals were calculated to compare DN to TPMT for effects on VAS, PPT, and NDI. Results Six randomized controlled trials with 241 participants total were included in this systematic review. The effect size of difference between DN and TPMT was non-significant for VAS [d = 0.41 (−0.18, 0.99)], for PPT [d = 0.64 (−0.19, 1.47)], and for NDI [d = −0.66 (−1.33, 0.02)]. Conclusions Both DN and TPMT improve pain and function in the short to medium term. Neither is more superior than the other.