Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease.

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.

COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

Intestinal failure-associated liver disease (IFALD): insights into pathogenesis and advances in management.

Premature infants and children with intestinal failure (IF) or short bowel syndrome are susceptible to intestinal failure-associated liver disease (IFALD, previously referred to as parenteral nutrition-associated liver disease, or PNALD). IFALD in children is characterized by progressive cholestasis and biliary fibrosis, and steatohepatitis in adults, and is seen in individuals dependent upon prolonged administration of PN. Many factors have been proposed as contributing to the pathogenesis of IFALD. In recent years, the focus has been on the potential synergistic roles of the intestinal microbiome, increased intestinal permeability, activation of hepatic innate immune pathways, and the use of intravenous soybean-oil-based intravenous lipid emulsions (SO-ILE). In vitro and in vivo studies have identified stigmasterol, a component of the plant sterols present in SO-ILE, as playing an important role. Although various strategies have been adopted to prevent or reverse IFALD, most suffer from a lack of strong evidence supported by well-designed, prospective clinical trials with clearly defined endpoints. Reduction in the amount of SO-ILEs or replacement with non-SO-ILEs has been shown to reverse IFALD although safety and long-term effectiveness have not been studied. Medical and surgical modalities to increase intestinal adaptation, advance enteral feedings, and prevent central line bloodstream infections are also important preventative strategies. There is a continued need to conduct high-quality, prospective trials with clearly define outcome measures to ascertain the potential benefits of these strategies.

Highlights from the nutrition guidelines for cystic fibrosis in Australia and New Zealand.

Optimal nutrition care is important in the management of cystic fibrosis (CF). This paper summarises the '2017 Nutrition Guidelines for Cystic Fibrosis in Australia and New Zealand (NZ)'. CF dietitians formulated 68 practice questions which were used to guide a systematic literature search and review of the evidence for nutrition in CF. Identified papers underwent quality and evidence assessment using the American Dietetic Association quality criteria checklist and the National Health and Medical Research Council of Australia (NHMRC) rankings. Evidence statements, graded recommendations and practice points were developed covering core nutrition topics (assessment and nutrition interventions including oral, enteral and micronutrient supplementation); nutrition-related co-morbidities (including pancreatic insufficiency, CF-related diabetes, bone health and distal intestinal obstruction syndrome); and key new topic areas (genetic modulator therapies, overweight/obesity and complementary therapies). This paper showcases highlights from the guidelines, focussing on new topic areas and geographic and climate considerations for vitamin D, salt and hydration.

Temporal analysis of thyroid cancer management in a Melbourne tertiary centre.

BACKGROUND: The American Thyroid Association (ATA) management guidelines for thyroid cancer were revised in 2009. The aim of this study was to determine if management of thyroid cancer in our institution has changed in accordance with the introduction of the revised ATA guidelines (ATA2009 ), and to compare the characteristics and management of thyroid cancer in a Melbourne endocrine surgery unit over a 7-year period. METHODS: All patients treated by the Monash University Endocrine Surgery Unit for thyroid cancer between 2007 and 2013 were divided into two groups - the pre-ATA2009 group (2007-2010) and the post-ATA2009 group (2011-2013). Comparisons were made of the demographics, cytology, pathology, surgical outcome and adjuvant therapy using t-test and chi-squared tests. RESULTS: There were 333 patients in the pre-ATA2009 group and 342 patients in the post-ATA2009 group. Fewer non-diagnostic fine-needle aspiration cytology results were identified in the post-ATA2009 group (4% versus 0.9%; P = 0.01), while the rates of other fine-needle aspiration cytology categories were similar. There was a reduction in the use of radioactive iodine ablation in the post-ATA2009 group, both in the proportion of patients being treated (66% versus 48%; P < 0.001) and the dosages used (mean 96 mCi versus 80 mCi; P < 0.01), despite similar tumour size in both groups. CONCLUSION: The key changes in practice thought to be attributable to the 2009 revised ATA guidelines were the reduction in the use and dosage of radioactive iodine in the management of differentiated thyroid cancer.

[Current Conservative Treatment and Management Strategies of Skeletal Muscle Injuries]. / Konservative Therapie von Muskelverletzungen - Beurteilung aktueller Behandlungskonzepte.

Muscle injuries frequently occur during sport and are one of the commonest injuries. The diagnosis and treatment of muscle injuries impose high demands on medical treatment, in order to ensure successful regeneration and a rapid return to sport. Most of the injuries can be treated conservatively, as skeletal muscles have a high endogenous capacity for repair and regeneration. Conservative treatment includes initial on-field therapy. This is known as the "RICE" principle and is common and recommended for initial treatment for most sports injuries. The primary therapy target is to reduce pain, swelling and bleeding and thus to limit the initial inflammatory process and prevent further damage. During the first days after injury, brief immobilization helps to reduce the re-injury rate and accelerates the formation of granulation tissue. There are many possible additional treatments, including intramuscular injections, manipulation of the sacroiliac joint or rehabilitation programs, including stretching and strengthening. If the acute treatment phase is complete after 3 to 5 days, more active treatment, including trunk stabilisation, stretching and strengthening, can be started gradually. Despite their high prevalence, there have only been a few studies on the treatment and management of these injuries. The aim of this manuscript is to review the literature on the classification, pathobiology and treatment strategies for muscle injuries.

The concept of early labour in the experience of maternity in twentieth century Britain.

OBJECTIVE: This paper explores perceptions of time and experience in midwifery with particular reference to the concept of early labour. Health professionals and lay people are used to describing labour in terms of 'stages' which correspond to agreed notions of progress based on physiological features. However the understanding of labour which underpins them is not a static entity but is a product of a particular era and set of circumstances which are primarily socially rather than biologically mediated. DESIGN: The research uses a historical methodology to describe understanding of, and strategies around, the management of early labour. It includes a variety of source material, including midwifery and obstetric textbooks, midwifery casebooks, books of advice to women and the oral testimony of midwives and mothers. SETTING: Twentieth century Britain. The twentieth century was a period of significant philosophical and concrete change in maternity in Britain, with occupational hegemony developing around both midwifery and obstetrics, and with the concomitant institutionalisation of labour and birth. PARTICIPANTS: Mothers, midwives and doctors. FINDINGS: The evidence suggests that during the first half of the twentieth century early labour was not seen as a discrete period within the first stage of labour with specific features or associated issues. Instead it was a private and individual experience, which rarely involved the presence of either doctors or midwives. Women, and those around them, made the decision about what early labour meant and how they should respond to it. The development of divisions in labour and notions of what constituted 'normality' or 'abnormality' as regards the length of each stage, based on time and clinical features, developed as the setting for labour and birth moved from home to hospital in the second half of the twentieth century. Labour became more described and more proscribed, with a rash of textbooks aimed at both midwives and doctors, and with the growing visibility of the entire process of labour through the use of technological surveillance and through the fact that women labouring on a hospital bed were observable in a way that women labouring at home were not. KEY CONCLUSIONS AND IMPLICATIONS: To look for historical strategies around the management of entities such as early labour is to assume, ahistorically, that similar beliefs and issues existed in an earlier period, and that there perhaps existed strategies for management which could profitably be rediscovered for use in current maternity care. The evidence suggests that such divisions were not described or managed features of labour before the second half of the twentieth century. The use of history does, however, give insights into breaks and continuities in beliefs and practice over time, and demonstrates that beliefs about stages of labour and their management are, like other aspects of maternity, multi-faceted and complex in both origin and effect.

Modelos explicativos y posicionamiento paradigmático de profesionales de la salud y pacientes ante un mismo proceso de enfermedad / Explanatory models and paradigmatic position of nurses and patients when faced with the same disease process

Los profesionales de Enfermería en el desarrollo de su trabajo tienen un contacto permanente con los pacientes, sin que el profesional sea consciente de los diferentes marcos referenciales que sobre el concepto de salud/enfermedad tienen los pacientes y ellos mismos. Objetivo del estudio: desvelar mediante el método etnográfico los modelos explicativos que enfermeras y pacientes manejan ante un mismo proceso de enfermedad (hipertensión y diabetes) e identificar la posición paradigmática en la relación enfermera-paciente. Material y método: el estudio se llevó a cabo desde una aproximación cualitativa. Escenario social: dos centros de salud de Ciudad Real en2010. Participantes: personas con diabetes y/o hipertensión arterial. Método de recogida de datos: observación durante el encuentro clínico entre la enfermera y el paciente y posteriormente entrevista semiestructurada a ambos. Análisis e interpretación: análisis de contenido de las entrevistas y de las metáforas utilizadas. Resultados: se realizaron un total de ocho entrevistas a pacientes y dos a enfermeras. Discusión: el desconocimiento demostrado por los enfermos parece estar relacionado con su nivel de instrucción y la clara influencia del paradigma racional tecnológico, habiendo evolucionado las enfermeras hacia el paradigma hermenéutico. Conclusiones: entender el modelo explicativo del otro es una oportunidad de acercamiento y de iniciar un proceso de cambio en el que el pacientes e corresponsabilice de sus autocuidados (AU)

Nursing professionals in the development of their work have regular contact with patients, without the professional being aware of the different frames of reference that patients have regarding the concept of health/illness and about themselves. Study objectives: to reveal by means of the ethnographic method the explanatory models that nurses and patients manage when faced with the same disease process (hypertension and diabetes) and to identify the paradigmatic position in the nurse-patient relationship. Material and method: qualitative study with ethnographic method that was conducted in two primary care centers of Ciudad Real in 2010. Participants were people with diabetes and/or arterial hypertension and the centre’s nurses. The used techniques were participant observation during the clinical meeting between the nurse and the patient, and subsequently, the semi-structured interview in both. Analysis and interpretation: contents analysis of the interviews and metaphors used. Results: there were a total of eight interviews to patients and to two nurses. Discussion: the lack of knowledge shown by patients appears to be related to their level of education and the influence of rational technological paradigm in which they are implemented, with nurses having evolved toward a hermeneutic paradigm. Conclusions: understanding the explanatory model of the other is an opportunity to approach and initiate a process of change in which the patient shares the responsibility of their self-care (AU)

Missing elements revisited: information engineering for managing quality of care for patients with diabetes.

INTRODUCTION: Advances in information technology offer new avenues for assembling data about diet and care regimens of diabetes patients "in the field." This creates a challenge for their doctors and the diabetes care community--how to organize and use new data to produce better long-term outcomes for diabetes patients. METHODS: iAbetics approaches the challenge as a quality management problem, drawing on total quality concepts, which in turn are grounded in application of the scientific method. We frame the diabetes patient's quality-of-care problem as an ongoing scientific investigation aimed at quantifying and predicting relationships between specific care-management actions and their outcomes for individual patients in their ordinary course of life. RESULTS: Framing diabetes quality-of-care management as a scientific investigation leads to a seven-step model termed "adaptive empirical iteration." Adaptive empirical iteration is a deliberate process to perfect the patient's choices, decisions, and actions in routine situations that make up most day-to-day life and to systematically adapt across differences in individual patients and/or changes in their physiology, diet, or environment. The architecture incorporates care-protocol management and version control, structured formats for data collection using mobile smart phones, statistical analysis on secure Web sites, tools for comparing alternative protocols, choice architecture technology to improve patient decisions, and information sharing for doctor review. CONCLUSIONS: Adaptive empirical iteration is a foundation for information architecture designed to systematically improve quality-of-care provided to diabetes patients who act as their own day-to-day care provider under supervision and with support from their doctor. The approach defines "must-have" capabilities for systems using new information technology to improve long-term outcomes for diabetes patients.

Challenges and opportunities in achieving healing.

The current health care system in the United States must shift from a primary focus on acute care and cure to also emphasize maintenance of function and the relief of suffering that derives from the ailments associated with chronic disease and illness. To achieve this goal, the individual components of the health care equation must all respond and work in concert. These components include the provider, the venue, the patient, the community, our society, and the fiscal realities of paying for care. However, the barrier for change stems from the marked heterogeneity that exists in the definition of each of these individual components. Thus, the fundamental question is, can our current and future medical care system respond to the imperative of focusing on healing with a particular emphasis on chronic diseases? A solution is the provision of individualized care in a mindful practice and the purposeful cultivation of a healing relationship suffused with compassion and empathy in the therapeutic alliances between patient, provider, and advocates.

Cardiovascular multimorbidity, emerging coalescence of the integrated panvascular approach.

Cardiovascular diseases are systemic processes frequently involving multiple vascular beds. Cardiovascular multimorbidity, arbitrarily defined as a clinically relevant disease of at least two major vascular beds in a single individual is frequent occurring in 30% to 70% of patients depending on the patient population. Management of patients with cardiovascular multimorbidity is complex requiring an interdisciplinary consensus and coordination. A panvascular concept of an interdisciplinary integrated management of these patients is introduced.