Clinical Practice Guideline Update Research Articles

Diagnostic yield of upper tract imaging performed for hematuria screening: Results from a national, privately-insured cohort

ObjectivesTo increase the population-level understanding of upper tract imaging evaluation during risk-based hematuria assessment. Using a national, privately-insured cohort, we evaluated the rates of imaging and the diagnostic yield of each imaging modality. We hypothesized that the rate of upper tract disease would be low and that the benefit of computed tomography over renal ultrasound would be limited. MethodsWe identified patients with an incident diagnosis of microscopic or gross hematuria between 2010 and 2015 within the MarketScan database. Multivariable logistic regression was used to predict the adjusted likelihood of any upper tract finding, with a subset analysis limited to malignant outcomes. ResultsWe identified 466,710 patients; 150,880 (32.3%) received ultrasound, 219,449 (47.0%) received computed tomography, and 96,381 (20.7%) received other imaging. Ultrasound detected 1,469 findings among 150,880 patients (1%); computed tomography detected 3,764 findings among 219,449 patients (1.7%); other imaging detected 2,612 findings among 96,381 patients (2.7%) (P < 0.0001). When adjusted for comorbidities, increased age, male sex, increased Elixhauser index, gross hematuria, and CT or other imaging were associated with upper tract findings, in the overall and subset analysis (all p < 0.0001). ConclusionsThe diagnostic yield of imaging is higher than expected; however, the detection rate remained low. As supported by updated clinical practice guidelines, clinicians should pursue risk-based imaging strategies during hematuria evaluation, although these data may support increased utilization of ultrasound at the initial evaluation.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

ObjectiveThe Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a ‘living document’.Design and main outcome measuresCritical appraisal of CDH literature...

Diagnostic accuracy of using capnography in verification of nasogastric tube placement among adult patients in hospital settings: Protocol of a diagnostic study.

To determine the diagnostic accuracy of end-tidal carbon dioxide (ETCO2) detection using capnography for verifying the correct placement of nasogastric tubes (NGTs) among adult patients in hospital settings. A prospective observational diagnostic study will be conducted. Patients ≥ 18-year-old and requiring the insertion of an NGT will be recruited using a convenience sampling method from 39 general medical and geriatric wards, intensive care units, accident and emergency departments, and subacute/rehabilitation/infirmary wards in 21 acute or subacute/convalescent/extended care hospitals. ETCO2 detection by sidestream capnography, which indicates an airway intubation of an NGT when a capnogram waveform or an ETCO2 level > 10mmHg (1.33 kPa) occurs, will serve as the index test. The reference standards will be the X-ray performed and pH value of gastric aspiration (pH ≤ 5.5) after the index test. Each participant will be included only once. Sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve of capnography will be calculated to assess the diagnostic performance of capnography. The variability in diagnostic accuracy in participants with different characteristics will be explored by using chi-squared or Fisher's exact tests. The time spent and the cost of the tests will be compared using the paired t-test. All statistical tests will be two-sided with a level of significance set at 0.05. This study will provide evidence on the diagnostic accuracy of capnography in verifying NGT placement and its applicability to patients in hospitals settings, since this evidence is limited in the current literature. In addition, it will help identify the optimal combination of tests in verifying the correct placement of NGTs and inform the update of clinical practice guidelines and stakeholders' decisions on the adoption of ETCO2 detection as a routine method for verifying NGT placement. ClinicalTrials.gov ID: NCT05817864.

Fever and neutropenia in pediatric oncology and stem cell transplant patients: an editorial commentary on updated international clinical practice guidelines

Fever and neutropenia in pediatric oncology and stem cell transplant patients: an editorial commentary on updated international clinical practice guidelines

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance.

Lloyd RM, Crawford T, Donald R, etal. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

Shedding light on the management of acute radiation dermatitis: insight from the MASCC Oncodermatology study group.

This paper highlights a collection of eleven recently published manuscripts on the prevention and management of acute radiation dermatitis. These meta-analyses provide additional evidence for the updated clinical practice guidelines by the Multinational Association of Supportive Care in Cancer (MASCC) Oncodermatology study group for prevention and management of acute radiation dermatitis. The collection of papers elucidate the currently available evidence on acute radiation dermatitis, highlighting consolidated knowledge, effective treatments, and proposed areas for future clinical trials. Overall, a total of 51 randomized controlled trials were retrieved and included for quantitative analysis of an initial systematic review of literature from 1946 to January 2023. Discussion of the clinical impact of various therapeutic interventions include: antiperspirant and deodorant use, barrier films and dressings, natural and miscellaneous agents, photobiomodulation therapy, topical corticosteroids, topical non-steroidal agents, skin hygiene and washing, as well as StrataXRT and Mepitel film in breast cancer patients. The comprehensive nature of the meta-analyses and their related findings may help reduce the discrepancies in in treatment of acute radiation dermatitis and facilitate consistency of therapeutic interventions employed in clinical practice worldwide.

Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, and Larynx: A Scoping Review of Treatment Guidelines Worldwide.

Head and neck cancer (HNC) treatments have been based on single or multimodal therapies with surgery, radiotherapy (RT), chemotherapy, and immunotherapy. However, treatment recommendations among countries may differ due to technological/human resources and usual local practices. This scoping review aims to identify, compare, and map the clinical practice guidelines (CPGs) for treating squamous cell carcinoma (SCC) of the oral cavity, oropharynx, and larynx worldwide. A search strategy on global CPGs for HNC was performed by using five electronic databases and grey literature. CPGs were selected for inclusion using EndNote-20 and Rayyan online software. No language or publication date restrictions were applied. The results were analyzed descriptively considering the most updated CPG version. In total, 25 CPGs covering the head and neck region (10), the larynx (7), the oral cavity (5), and the oropharynx (3), were found in 13 geographical regions, and 19 were developed by medical societies from 1996 to 2023. Surgery and RT remain the main modalities for early-stage HNC, with surgery preferred in low-resource countries, and RT in selected cases, especially in the larynx/oropharynx aiming to achieve a cure with organ preservation. Human papillomavirus infection for oropharyngeal SCC is not tested in some Asian countries and there is still no consensus to treat p16-positive cases differently from p16-negative. Recommendations for larynx preservation vary according to facilities in each country, however, individualized choice is emphasized. Inequality across countries/continents is evident, with a similar pattern of recommendations among developed as well as developing ones. No CPGs were found in Latin America as well as Oceania countries, where the incidence of HNC is high and limitations of access to treatment may be encountered.

Central Disorders of Hypersomnolence.

The goals of this article are to describe the clinical approach to and management of patients with central disorders of hypersomnolence, and to understand and differentiate available diagnostic tools. Updated clinical practice guidelines for the treatment of central disorders of hypersomnolence and narcolepsy specifically highlight new treatment options. Approval for a lower-sodium oxybate formulation that contains 92% less sodium than the standard sodium oxybate for the treatment of narcolepsy and idiopathic hypersomnia adds to the number of medications available for these disorders, allowing for a more tailored management of symptoms. Central disorders of hypersomnolence are characterized by excessive daytime sleepiness that impacts daily functions. These disorders can be differentiated by obtaining a detailed clinical sleep history and by a thoughtful interpretation of sleep diagnostic testing. Tailoring treatment approaches to meet the needs of individuals and accounting for medical and psychiatric comorbidities may improve quality of life.

A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity.

The prevalence of pediatric obesity has increased exponentially over the past four decades. The American Academy of Pediatrics recently released updated clinical practice guidelines highlighting the importance of identifying pediatric obesity as a chronic disease. The guidelines support consideration of concurrent treatment with intensive lifestyle interventions, obesity pharmacotherapy, and bariatric surgery. The dramatic rise in pediatric obesity has spurred interest in utilizing obesity pharmacotherapy to support sustained weight reduction in pediatric cohorts, in the hopes of preventing the emergence of later-appearing, significant co-morbidities. Despite the enormous demand, the obstacles posed by performance of needed clinical trials in the pediatric population markedly limits available pharmacotherapy for the treatment of obesity in pediatrics. Currently, there are five medications approved by the Food and Drug Administration for use in youth with obesity. In 2022, the phentermine/topiramate (PHEN/TPM), once-daily, controlled-release, combination product received FDA approval, for the indication of chronic weight management, in youth with obesity, ages 12 years and older. The objectives of this narrative review are to: (1) Review the mechanism of action of phentermine and topiramate, (2) Summarize the safety and efficacy data of topiramate and phentermine use as both monotherapies and in combination, and (3) Discuss clinical practice guidelines and clinical implications, for the use of these agents in youths with obesity.

Management of cirrhotic ascites: Seven-step treatment protocol based on the Japanese evidence-based clinical practice guidelines for liver cirrhosis 2020.

Liver cirrhosis is a severe illness, associated with multiple complications, which can lead to liver failure. One of the major complications of cirrhosis is ascites. This review describes a stepped treatment approach for the management of ascites in Japanese patients with cirrhosis. It is broadly based on the 2020 update of the Japanese clinical practice guidelines for liver cirrhosis, which is briefly compared with guidelines from Europe and the United States. Step 1 is sodium restriction at a level suitable for Japanese individuals (5-7 g/day), Step 2 is albumin treatment to counteract underlying hypoalbuminemia, Step 3 is initiation of diuretic treatment with spironolactone, followed by add-on loop diuretic treatment at Step 4. Patients refractory to sodium restriction and sodium diuretics can be treated with tolvaptan (Step 5) - a vasopressin V2 receptor antagonit that is available in Japan. Patients at Steps 6 and 7 have refractory ascites and are treated with large volume paracentesis (LVP) in combination with an albumin infusion. High-dose albumin infusion (6-8 g/L) at the time of LVP has recently become possible in Japan. Cell-free and concentrated ascites reinfusion therapy (CART) is also an option at Step 6. Two of the treatment options at Step 7 are limited in Japan (transjugular intrahepatic portosystemic shunts are not approved, and access to liver donors is very limited), but patients can undergo a peritoneovenous shunt if no other options are available. While challenges remain in the treatment of ascites, adopting this stepwise treatment approach may improve patient outcomes. This article is protected by copyright. All rights reserved.

Lithium related thyroid and parathyroid disease: Updated clinical practice guidelines are needed

ObjectiveThis study aims to estimate the prevalence of and determine physician approaches to the screening and management of lithium-associated thyroid and parathyroid disorders in British Columbia, Canada. MethodsSerum lithium and thyroid/parathyroid laboratory data were collected retrospectively for patients with lithium levels measured at seven BC hospitals between 2012 and 2021. A mail-out survey about screening and management of thyroid/parathyroid disorders in patients on lithium was sent to the ordering physicians of patients with abnormal results. Three months after, a follow-up questionnaire was sent to respondents, and the original survey was re-sent to non-responders. ResultsOf 4917 patients, 1.9 % had PTH (mean 22.33 ± 23.00 pmol/L) and 77.1 % had TSH (mean 3.61 ± 6.69 pmol/L) measured. Of 222 hypercalcemic patients (defined as any serum calcium or ionized calcium above the laboratory reference), 17.6 % had a PTH level measured. From 294 surveys sent to 214 physicians, the overall response rate was 31.6 % (n = 93) with twelve fully completed surveys. All twelve respondents monitored TSH levels every 6–12 months, and eight physicians monitored PTH and/or calcium at variable intervals. Two physicians routinely ordered both thyroid and parathyroid screening laboratory tests. Of the 80 non-respondents, limited patient contact was the most common reason for opting out (n = 27). ConclusionsOur results suggest biochemical screening for lithium-associated parathyroid disorders is less common than for thyroid disorders. There is insufficient data to determine the true prevalence of lithium-associated thyroid and parathyroid disorders. This highlights the need for updated clinical guidelines for management of lithium-associated thyroid and parathyroid disorders.

Diagnosis of Obesity: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity.

The prevalence of obesity has consistently increased worldwide, and many obesity-related diseases are emerging as major health problems. Body mass index (BMI) is used to define obesity and is highly correlated with body fat mass. Moreover, obesity-related morbidities increase linearly with the increase in BMI. The Korean Society for the Study of Obesity defined overweight as a BMI ≥23 kg/m2 and obesity as a BMI ≥25 kg/m2, based on a significant increase in obesity-related diseases. A waist circumference of ≥90 cm in men and ≥85 cm in women are defined as abdominal obesity, which is also correlated with obesity-related diseases. These diagnostic criteria are the same as in the previous version; however, the updated guidelines put greater emphasis on the use of morbidity as the basis for obesity and abdominal obesity diagnoses. These new guidelines will help to identify and manage high-risk groups for obesity-related comorbidities among Korean adults.

Diagnosis of Obesity: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity.

The prevalence of obesity has consistently increased worldwide, and many obesity-related diseases are emerging as major health problems. Body mass index (BMI) is used to define obesity and is highly correlated with body fat mass. Moreover, obesity-related morbidities increase linearly with the increase in BMI. The Korean Society for the Study of Obesity defined overweight as a BMI ≥23 kg/m2 and obesity as a BMI ≥25 kg/m2, based on a significant increase in obesity-related diseases. A waist circumference of ≥90 cm in men and ≥85 cm in women are defined as abdominal obesity, which is also correlated with obesity-related diseases. These diagnostic criteria are the same as in the previous version; however, the updated guidelines put greater emphasis on the use of morbidity as the basis for obesity and abdominal obesity diagnoses. These new guidelines will help to identify and manage high-risk groups for obesity-related comorbidities among Korean adults.

Part I: Interactive case: Menopause

Part I: Interactive case: Menopause

0577 Clinically Meaningful Improvements With Pitolisant in Adults With Narcolepsy: Pooled Analysis of Randomized Clinical Trials

Abstract Introduction Narcolepsy is characterized by symptoms indicative of sleep–wake dysregulation, notably excessive daytime sleepiness (EDS) and cataplexy. In 2021, the American Academy of Sleep Medicine (AASM) updated its clinical practice guidelines on the treatment of central disorders of hypersomnolence. The AASM identified clinical significance thresholds (CSTs) of a 2-point reduction in Epworth Sleepiness Scale (ESS) score and a 25% reduction in the frequency of cataplexy, amongst others, to compare posttreatment effects between intervention and placebo. This post hoc analysis evaluates the efficacy of pitolisant in the treatment of patients with narcolepsy using these updated CSTs. Methods Data were pooled from 2 randomized, placebo-controlled, 7- and 8-week studies (HARMONY-1, HARMONY-CTP) of pitolisant in adults with narcolepsy. Pitolisant was individually titrated over a 3-week period (maximum potential dose, 35.6 mg/day), and the dose remained stable thereafter. The analysis population for EDS included all patients who received pitolisant or placebo (ESS score ≥12 required for study inclusion). The analysis population for cataplexy included treated patients who experienced ≥3 attacks per week at baseline. The end-of-treatment value for the ESS was the score at the last study visit (last observation carried forward [LOCF]). The cataplexy endpoint was the weekly rate of cataplexy (WRC) during the stable dose period (LOCF). Results Data from 166 patients for EDS (pitolisant, n=85; placebo, n=81) and 122 patients for cataplexy (pitolisant, n=64; placebo, n=58) were analyzed. Mean (SD) baseline ESS score was 17.6 (3.0) in the pitolisant group and 17.9 (3.1) in the placebo group. Mean (SD) baseline WRC was 12.4 (10.7) and 9.9 (9.0), respectively. At the end of treatment, ESS score reduction of ≥2 points was observed in a significantly greater percentage of patients in the pitolisant group (72.9%) as compared with the placebo group (45.7%; P&amp;lt; 0.001). The percentage of patients with a reduction in WRC of ≥25% was significantly greater with pitolisant (78.1%) versus placebo (34.5%, P&amp;lt; 0.001). Conclusion Pitolisant provides statistically significant and clinically meaningful reductions in EDS and cataplexy in patients with narcolepsy, based upon the CSTs associated with the updated AASM clinical practice guidelines. Support (if any) Bioprojet Pharma and Harmony Biosciences, LLC.

Cyanoacrylate adhesive closure in the European and American 2022 clinical practice guidelines

Over the last decade non-thermal non-tumescent (NTNT) methods of truncal reflux elimination in chronic venous disease (CVD) are becoming increasingly popular. The main NTNT modalities are mechanochemical ablation and cyanoacrylate adhesive closure (CAC). The advantages of non-thermal ablation are avoidance of tumescent anesthesia, low periprocedural pain and bruising, high patient comfort and satisfaction rates. CAC method has an additional benefit of avoiding the postprocedural compression. CAC is one of promising non-thermal ablation procedures, that leads to truncal vein occlusion and reflux elimination via endovenous delivery of n-butyl-2-cyanoacrylate. This review is aimed at assessment of the updated European and American clinical practice guidelines on CVD management, particularly the role of CAC. Current evidence shows high efficacy and safety of the CAC, its advantages regarding the periprocedural pain and ecchymoses, risk of adverse events, closure rates in the long-term, procedure and recovery time and patients’ quality of life. Therefore, along the current gold standard of varicose vein treatment – thermal ablation, the updated 2022 European and American clinical practice guidelines have significantly emphasized the role of NTNT modalities in general and CAC in particular. Specifically, the European Society for Vascular Surgeons guidelines recommend CAC for patients with great saphenous vein (GSV) incompetence when the NTNT technique is preferred. American guidelines recommend both thermal and non-thermal ablation for the patients with symptomatic axial reflux of the GSV, depending on the available expertise of the treating physician and the preference of the patient.

Treatment of breakthrough and prevention of refractory chemotherapy-induced nausea and vomiting in pediatric cancer patients: Clinical practice guideline update.

This clinical practice guideline update provides recommendations for treating breakthrough chemotherapy-induced nausea and vomiting (CINV) and preventing refractory CINV in pediatric patients. Two systematic reviews of randomized controlled trials in adult and pediatric patients informed the recommendations. In patients with breakthrough CINV, escalation of antiemetic agents to those recommended for chemotherapy of the next higher level of emetogenic risk is strongly recommended. A similar recommendation to escalate therapy is made to prevent refractory CINV in patients who did not experience complete breakthrough CINV control and are receiving minimally or low emetogenic chemotherapy. A strong recommendation to use antiemetic agents that controlled breakthrough CINV for the prevention of refractory CINV is also made.

Adoption of clinical practice guidelines in cases of benign paroxysmal positional vertigo.

Despite being one of the most common types of the peripheral vertigo encountered in clinical practice, benign paroxysmal positional vertigo (BPPV) remains underdiagnosed and undertreated, even in affluent health care systems. The publication of fully updated clinical practice guidelines significantly facilitated the diagnosis and treatment of BPPV. This study evaluates the adoption of the guidelines in our clinical setting and reviews further recommendations for quality-of-care improvement. This retrospective cross-sectional survey included a total of 1155 adult patients diagnosed with BPPV at the biggest tertiary care center in the country during a 5-year period (2017-2021). The data for the first three years (2017-2020) and 919 patients were collected in full, and for the remaining 236 patients (2020-2021) only partially due to the disturbance in referrals caused by COVID-19 pandemic. The familiarity with and adherence to the published clinical guidelines by physicians judged by patients' charts and our health care database were overall unsatisfactory. The adherence varied from 0 to 40.5% in our sample. The recommendations for making the diagnosis and for repositioning procedure as first-line therapy were followed in only 20-30% of cases. There are large opportunities for improvement in quality of care of BPPV patients. Apart from constant and systematic education at the primary health care level, the health care system may need to adopt more advanced measures of ensuring better adherence to guidelines and subsequent reduction in medical costs.

Temporomandibular disorders: current status of research, education, policies, and its impact on clinicians in the United States of America.

Temporomandibular disorders (TMDs) encompass a number of different musculoskeletal disorders often accompanied by pain and dysfunction. Most TMDs are acute, but can become chronic leading to disability and quality of life issues. There is wide variation in treatment of TMDs, including both conservative/reversible therapies as well as invasive/irreversible treatments, which present difficulties for clinicians, patients, and third-party payers as to what constitutes appropriate care. Data sources: A recent report by the National Academies of Sciences, Engineering, and Medicine highlighted a number of deficiencies, most notably in the education of TMDs within United States of America dental schools at both the predoctoral and postdoctoral (dental) levels as well as addressing the historic inconsistencies in both diagnosis and treatment. New areas for research and interprofessional collaboration should assist in the understanding of TMDs, and updated clinical practice guidelines should help reduce variation in the delivery of evidence-based care. Recently, the American Dental Association recognized orofacial pain as a specialty, which should increase the level and availability of expertise in treating these issues. Summary: Based on the current best evidence, this report is an attempt to alert the profession to discontinue irreversible and invasive therapies for the vast majority of TMDs and recognize that the majority of these disorders are amenable to conservative, reversible interventions.

2021 CLINICAL PRACTICE GUIDELINES IN THE EVALUATION AND MANAGEMENT OF PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA

The Clinical Practice Guidelines (CPG) for the Diagnosis and Management of Pediatric Community-Acquired Pneumonia (PCAP) was initiated by the Philippine Academy of Pediatric Pulmonologists, Inc. (PAPP) and the Pediatric Infectious Disease Society of the Philippines (PIDSP), in cooperation with Philippine Pediatric Society, Inc. (PPS) way back in 2004. Several CPG updates were then undertaken by the PAPP PCAP CPG Task Force from 2008 to 2016. Clinically-relevant research questions were answered with recent and current recommendations based on evidence from local and international data. The 2021 PCAP CPG initiative was envisioned in March 2018 upon the recommendations of the 2018 PAPP Board for the purpose of updating the evidence in the PCAP CPG 2016 clinical questions. This led to the collaboration of PAPP and PIDSP to develop this CPG. Individual members were identified from each society as content experts to form the Steering Committee along with a clinical epidemiologist and technical writer as review experts. The committee identified the scope and target end user of the CPG as well as additional clinical questions to be included in the 2021 update aside from the questions on the previous CPGs. Selected members from the two societies formed the Technical Working Group (TWG) who did the literature search, appraisal of evidences, and formulation of recommendations. These recommendations were then presented to the stakeholders who became part of the consensus panel. There was no identified conflict of interest among the CPG developers, TWG members and stakeholders. A survey to determine potential competing interests were conducted during the development of this CPG. This initiative was fully funded by the PAPP and PIDSP societies. The 2021 PCAP CPG significantly differs from the previous CPGs in several aspects. First, the current guideline is a consensus between two pediatric societies. Second, much of the literature review has been centered on meta-analyses or systematic reviews instead of individual studies. Finally, appraisal of published literature was based on Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. Such methodological differences may provide difficulties in defining evolution of care through the years.