Validação do conteúdo de um protocolo de avaliação da motricidade orofacial em lactentes / Content validation of an orofacial myofunctional assessment protocol for infants / Validación del contenido de un protocolo para la evaluación de la motricidad orofacial en bebés

Introdução: Muitos estudos têm se dedicado a compreender melhor a dinâmica da avaliação das estruturas e funções estomatognáticas de lactentes; até a presente pesquisa não foram encontrados estudos específicos para essa faixa etária, até recentemente. Objetivo: Validar o conteúdo de um instrumento fonoaudiológico de avaliação da motricidade orofacial para lactentes na faixa etária de um mês a dois anos. Metodologia: Foi elaborado o instrumento para "avaliação fonoaudiológica da motricidade orofacial de lactentes de um mês a dois anos" a partir dos dados obtidos na literatura. A validação do conteúdo do instrumento se deu por meio da avaliação de quatro juízes para clareza dos itens propostos no protocolo e da representatividade dos mesmos no processo de validação do conteúdo. Os juízes classificaram cada item quanto à clareza, a partir de uma escala tipo Likert de quatro pontos, sendo: (4) muito claro, (3) claro, (2) pouco claro, (1) sem clareza, com o propósito de realizar a validação do conteúdo por meio da aplicação da equação do Índice de Validação do Conteúdo (IVC). Resultados: O protocolo desenvolvido possui 8 itens e uma breve anamnese: Hábitos Orais; Avaliação Estrutural; Respiração; Voz; Avaliação Funcional; Alimentação e Deglutição - líquidos e alimentos em pedaços; Diagnóstico Fonoaudiológico. A etapa seguinte contou com a análise da representatividade e para clareza dos itens do protocolo pelos juízes, e após a segunda análise, a validação do conteúdo resultou na permanência dos 8 itens com Índice de Validade de Conteúdo total de 100%. Conclusão: O conteúdo do protocolo foi considerado válido para uso na avaliação do público-alvo, comprovado por profissionais com experiência na área. A versão final do Protocolo de avaliação fonoaudiológica da motricidade orofacial de bebês foi finalizada com 8 itens de avaliação. (AU)

Introduction: The instruments for evaluating the structures and functions of the stomatognathic system in babies have been lacking in studies. Objective: To validate the content of a speech-language instrument to assess orofacial motricity for babies aged between one month and two years old. Methodology: The instrument for "speech-language assessment of the orofacial motricity of babies from one month to two years old" was created based on the data obtained by the integrative review. The instrument's content was validated through the evaluation of four judges. The judges classified each item according to clarity, based on a four-point Likert scale, as follows: (4) very clear, (3) clear, (2) lightly clear, (1) unclear, to perform content validation by applying the Content Validation Index (CVI) equation. Results: The developed protocol has eight items and a brief anamnesis: Oral Habits; Structural Assessment; Breathing; Voice; Functional Assessment; Feeding and Swallowing - liquids and food in pieces; and Speech-Language Diagnosis. The next step included the analysis of the representativeness of the protocol items by the judges. After the second analysis, the validation of the content resulted in the permanence of the eight items with a total Content Validity Index of 100%. Conclusion: The content of the protocol was considered valid for use in the evaluation of the target audience, proven by people with experience in the area. The final version of the Protocol for the Speech-Language Pathology Assessment of Orofacial Motricity in Babies was completed with eight assessment items. (AU)

Introducción: Los instrumentos para la evaluación de las estructuras y funciones del sistema estomatognático en los bebés han mostrado falta de estudios. Objetivo: Validar el contenido de un instrumento de fonoaudiología para la evaluación de la motricidad orofacial en bebés de un mes a dos años de edad. Metodología: Inicialmente, se llevó a cabo la elaboración del instrumento para la "evaluación logopédica de la motricidad orofacial de bebés de un mes a dos años de edad" propiamente dicho, a partir de los datos obtenidos por la revisión integradora. La validación del contenido del instrumento se realizó a través de la evaluación de cuatro jueces. Los jueces calificaron cada ítem en términos de claridad, utilizando una escala de Likert de cuatro puntos, de la siguiente manera: (4) muy claro, (3) claro, (2) poco claro, (1) poco claro, con el propósito de realizar la validación de contenido a través de la aplicación de la ecuación del Índice de Validación de Contenido (CVI). Resultados: después de la lectura y discusión de los artículos, fue posible desarrollar el protocolo que contiene 8 ítems y una breve anamnesis, que son: Hábitos Orales; Evaluación Estructural; Respiración; Voz; Evaluación Funcional; Alimentación y deglución: líquidos y alimentos en trozos; y; Diagnóstico de Patología del Habla-Lenguaje. El siguiente paso fue el análisis de la representatividad de los ítems del protocolo por parte de los jueces, y luego del segundo análisis, la validación de contenido resultó en la permanencia de 8 ítems con un Índice de Validez de Contenido total del 100%. Conclusión: El contenido del protocolo se consideró válido para su uso en la evaluación del público objetivo, confirmado por personas con experiencia en el área. La versión final del Protocolo de evaluación de la patología del habla y el lenguaje para la motricidad orofacial en bebés se completó con 8 ítems de evaluación. (AU)

RIGHT for acupuncture: An extension of the RIGHT statement for clinical practice guidelines on acupuncture.

OBJECTIVE: In 2017, the International Standard for Reporting Items for practice Guideline in HealThcare (RIGHT) published reporting guidelines to enhance transparency and clarity in the process of developing clinical practice guidelines (CPGs). Given the original tool was developed in 2017 and demanded in developing and reporting high quality of acupuncture CPGs, an extension with a focus on a specific reporting checklist was warranted. STUDY DESIGN AND SETTING: The study was designed based on the methodology recommended by the Enhancing the Quality and Transparency Of Health Research (EQUATOR) Network with modification accordingly. A reporting checklist and its elaboration and explanations for users were developed. RESULTS: A checklist of seven sections (Basic information, Background, Evidence, Recommendations, Funding, Declaration and management of interest, Other information), twenty-three first level items and forty-three second level items was developed. We clarified the rationales of the items and provided explanations and examples of each item for additional guidance. CONCLUSION: The RIGHT for Acupuncture checklist identifies a set of items to be reported when reviewing clinical practice guidelines on acupuncture. This extension can be expected to improve the reporting quality of CPGs on acupuncture.

Cross-insitutional standardization of imaging protocols - A pilot study within the scope of the Comprehensive Cancer Center Lower Saxony. / Standortübergreifende Standardisierung von Untersuchungsprotokollen ­ eine Pilotstudie im Rahmen des Comprehensive Cancer Centers Niedersachen.

PURPOSE: Cross-institutional establishment of standardized protocols for CT and MR imaging of primary liver and pancreas tumors in an oncological center. MATERIALS AND METHODS: This prospective dual-institution study was approved by the local IRBs. Minimum requirements (phases, sequences, slice thickness) for imaging of primary liver and pancreas tumors were defined and implemented at both sites. Between 06/19 and 08/19 in-house examinations were evaluated in terms of compliance with defined protocols and image quality. In addition, extramural examinations that were demonstrated at interdisciplinary tumor board meetings in the same study period were reviewed. Results were analyzed by means of descriptive statistics, and differences between centers, modalities and organs assessed (Fisher-exact Test, p < 0.05 deemed significant). RESULTS: 480 data sets (397 internal, 83 extramural) were included in this study and analyzed. Overall protocol compliance for in-house examinations was 93.5 % (371/397 datasets), without statistical significant difference between the two institutions (p = 0.0615). External studies met minimum requirements in 48.2 % (40/83 datasets). Regarding in-house imaging, significant differences were observed between CT of the liver and the pancreas (p < 0.05) and between CT and MRI of the pancreas (p < 0.05). CONCLUSION: As demonstrated in this pilot project, cross-institutional establishment of standardized imaging protocols is feasible with a compliance rate of more than 90 %. Standardized imaging protocols may serve as a quality indicator in oncological imaging, and over time, improve cross-institutional patient care. KEY POINTS: · Cross-institutional establishment of standardized imaging protocols is feasible with high compliance.. · Standards may serve as a quality indicator in oncological imaging.. · In perspective, cross-institutional patient care may be improved.. CITATION FORMAT: · Römermann I, Al-Bourini O, Seif Amir Hosseini A et al. Cross-insitutional standardization of imaging protocols - A pilot study within the scope of the Comprehensive Cancer Center Lower Saxony. Fortschr Röntgenstr 2021; 193: 410 - 416.

Elaboração de um protocolo de terapia nutricional para pacientes queimados em um centro de tratamento de referência: Relato de experiência / Elaboration of a nutritional therapy protocol for burned patients in a reference treatment center: Experience report

OBJETIVO: Descrever a trajetória da construção de um protocolo de terapia nutricional para pacientes queimados em um centro de tratamento de referência. RELATO DE EXPERIÊNCIA: Para a construção do protocolo, foi inicialmente elaborado um fluxograma sistematizando as etapas da atenção nutricional ao paciente queimado. Feito isso, percebeu-se a necessidade de construir um instrumento facilitador para tomada de decisões relativas à conduta nutricional. Com esta finalidade, foram realizadas estimativas das necessidades energéticas do paciente queimado, com base nas equações preditivas encontradas na literatura e em indivíduo de referência eutrófico, conforme perfil nutricional predominante na unidade. Os resultados foram dispostos em tabela comparativa, estratificados por sexo, faixa etária e percentual de superfície corporal queimada (%SCQ) e analisados para definir a melhor forma de estimar as necessidades energéticas dos pacientes na prática clínica. Ainda com base nesta estimativa, nas recomendações encontradas na literatura científica e na dieta oral padrão da unidade, que fornece aproximadamente 2548Kcal/dia e 105g/dia de proteína, foram elaboradas sugestões sobre quando e como prescrever suplementos orais nutricionalmente completos, módulo de proteína, glutamina e indicar terapia nutricional enteral para estes pacientes, conforme a %SCQ (<20%, 20%-30%, >40%). CONCLUSÃO: A aplicação deste protocolo na prática clínica pode otimizar a terapia nutricional do paciente queimado, de forma a minimizar a deterioração e/ou recuperar o estado nutricional destes pacientes, contribuindo para melhores desfechos clínicos.

OBJECTIVE: To describe the trajectory of the construction of a nutritional therapy protocol for burn patients in a reference treatment center. EXPERIENCE REPORT: For the construction of the protocol, initially a flowchart was prepared, systematizing the stages of nutritional care with burned patients. That done, it was realized the need to build a facilitating instrument for making decisions regarding nutritional conduct. For this purpose, estimates of the burned patient's energy needs were performed, based on the predictive equations found in the literature and in eutrophic reference individual, according to the predominant nutritional profile in the unit. The results were displayed in a comparative chart, stratified by sex, age and total body surface area (%TBSA) and analyzed to define the best way to estimate the energy needs of patients in clinical practice. Based on this estimate, in the recommendations found in the scientific literature and the unit's standard oral diet which provides approximately 2548Kcal/day and 105g/day of protein, suggestions were made about when and how to prescribe nutritionally complete oral supplements, protein module, glutamine and provide enteral nutritional therapy to these patients, according to %TBSA (<20%, 20%, 30%, >40%). CONCLUSION: The application of this protocol in clinical practice can optimize a nutritional therapy of the burned patient, in order to minimize the deterioration and/or recover their nutritional status, contributing to the best clinical outcomes.

Hipotermia terapêutica na encefalopatia hipóxico-isquêmica neonatal: revisão integrativa / Therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: integrative review / Hipotermia terapéutica em la encefalopatía hipóxico-isquémica neonatal: revisión integrativa

Objetivo: identificar evidências acerca do uso seguro da hipotermia terapêutica em recém-nascidos. Método: revisão integrativa realizada entre junho e julho de 2018, em fontes eletrônicas da Biblioteca Virtual de Saúde e PubMed, por meio da pergunta:"Que evidências podem subsidiar o cuidado de enfermagem voltado para a redução de sequelas em recém-nascidos submetidos à hipotermia terapêutica?".Foram eleitos nove artigos para análise, sendo oito internacionais e um nacional. Resultados:o resfriamento deve acontecer por 72 horas, com hipotermia leve. As indicações para inclusão no protocolo foram: primeiras seis horas de vida, idade gestacional maior que 35 semanas e acidose na primeira hora de vida.São cuidados essenciais: monitoração hemodinâmica, observação da pele, controle térmico retal, vigilância do Eletroencefalograma de Amplitude Integrada. Conclusão: a terapêutica apresenta benefícios, porém sua aplicação depende de protocolo institucional e treinamento das equipes com foco nas potenciais complicações.

Objective: to identify the evidence on safe use of therapeutic hypothermia in newborns. Method: integrative review of the literature, conducted between June and July of 2018, in electronic sources from the Virtual Health Library and PubMed, through the question: "What evidence can support nursing care aimed at reducing sequelae in newborns undergoing therapeutic hypothermia?". Analysis was conducted for nine selected article, being eight from international literature and one from Brazilian national literature. Results: cooling should occur for 72 hours with mild hypothermia. Indications for inclusion in the protocol were: first six hours of life, gestational age greater than 35 weeks and acidosis in the first hour of life. Essential care includes hemodynamic monitoring, skin observation, rectal thermal control, Integrated Amplitude Electroencephalogram surveillance. Conclusion: the therapy has benefits, but its application depends on institutional protocol and team training focusing on potential complications.

Objetivo: identificar la evidencia sobre el uso seguro de la hipotermia terapéutica en recién nacidos. Método: revisión integradora de la literatura, realizada entre junio y julio de 2018, en fuentes electrónicas de la Biblioteca Virtual de Salud y PubMed, a través de la pregunta: "¿Qué evidencia puede apoyar la atención de enfermería dirigida a reducir las secuelas en los recién nacidos que sufren hipotermia terapéutica?". Se realizaron análisis para nueve artículos seleccionados, ocho de literatura internacional y uno de literatura nacional brasileña. Resultados: el enfriamiento debe ocurrir durante 72 horas con hipotermia leve. Las indicaciones para la inclusión en el protocolo fueron: primeras seis horas de vida, edad gestacional mayor de 35 semanas y acidosis en la primera hora de vida. El cuidado esencial incluye monitoreo hemodinámico, observación de la piel, control térmico rectal, vigilancia integrada de electroencefalograma de amplitud. Conclusión: la terapia tiene beneficios, pero su aplicación depende del protocolo institucional y del entrenamiento del equipo, enfocándose en posibles complicaciones.

Comparative efficacy and safety of traditional Chinese patent medicine for anxiety disorders in children or adolescence: A protocol for systematic review and network meta-analysis.

BACKGROUND: Anxiety is the most common mental illness among adolescents and children, and its incidence is increasing year by year, which has a serious adverse effect on the academic and growth of adolescents and children. Conventional treatment methods such as oral administration of western medicine and psycho-behavioral therapy have obvious limitations. Chinese patent medicines play an irreplaceable role in the treatment of this disease. At present, there is no comparison of the safety and effectiveness of various Chinese patent medicines curing anxiety in adolescents. So we take advantage of the method of network meta-analysis to systematically compare the efficacy of various Chinese patent medicines curing this disease. METHODS: We will systematically and comprehensively search the following databases, including PubMed, Web of Science, EMBASE, The Cochrane Library, China BioMedical Literature (CBM), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), and Wanfang database. We will include all RCT trials that meet the inclusion criteria, starting from the establishment of the database until August 2020. Two researchers will independently screen the literature based on inclusion criteria. While extracting data, we also assess the risk of bias in the included studies. All the data and evidence obtained will be evaluated by the method of Bayesian network meta-analysis. STATA and WinBUGS software will be used. RESULTS: This study will evaluate the effectiveness and safety of various TCPMs for anxiety disorders in children or adolescence. CONCLUSION: The results of this study will provide valuable references for the clinical application of Traditional Chinese patent medicines, and assist clinicians in formulating more reasonable diagnosis and treatment strategies. ETHICS AND DISSEMINATION: This study does not require ethical approval. INPLASY REGISTRATION NUMBER: INPLASY202080048.

Acupotomy therapy for cervical vertigo: A protocol for a systematic review and meta-analysis.

BACKGROUND: Acupotomy has been widely used to relieve cervical vertigo (CV). However, the efficacy of acupotomy for CV is uncertain. The purpose of this study is to evaluate the efficacy and safety of the acupotomy for CV. METHODS: The following electronic databases will be searched to identify relevant randomized controlled trials (RCTs) for inclusion in the review from inception to April 2020: PubMed, the Cochrane Library, Embase, the China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Periodical Database, and Chinese Biomedical Literature Database. Two researchers will independently select studies, collect data, and assess the methodology quality by the Cochrane risk of bias tool. Meta-analysis will be completed by RevMan V.5.3 software. RESULTS: This systematic review will provide an assessment of the current state of acupotomy for CV, aiming to assess the efficacy and safety of acupotomy for Patients with CV. CONCLUSION: This systematic review will provide a credible Evidence-based for the clinical treatment of CV with acupotomy.PROSPERO registration number: CRD42019134712.

Effectiveness and safety of Guilu Erxian Glue (a traditional Chinese medicinal product) for the treatment of postmenopausal osteoporosis: A protocol for systematic review and meta-analysis.

BACKGROUND: The prevalence of postmenopausal osteoporosis is rapidly rising, with a high proportion of patients who are vulnerable to fractures and other chronic symptoms. The commonly applied Western medicine lacks cost-efficiency and tends to have various potential side effects. Guilu Erxian Glue (GEG), an orally taken traditional Chinese medicinal product, has been advocated to manage osteoporosis for a long period. However, the evidence of the efficacy of GEG on osteoporosis seems to be less convincing and conclusive. Therefore, the purpose of this study is to assess the effectiveness and safety of GEG on postmenopausal osteoporosis. METHODS: We will implement a systematic review and meta-analysis following the requests of the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P). The PubMed database, Scopus, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, VIP database, Sinomed, and grey literature sources will be retrieved for eligible studies. Randomized controlled trials investigating GEG in women with postmenopausal osteoporosis employing osteoporosis-associated outcomes measures will be eligible for inclusion. Two reviewers will independently complete the study selection procedure, data extraction, and risk of bias assessment. A third reviewer will mediate when irreconcilable discrepancies occur. Should sufficient clinical homogeneity exist, a meta-analysis will be conducted. Additionally, we will utilize the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of quantitative outcomes. RESULTS: The current systematic review and meta-analysis will provide the effectiveness and safety of GEG on postmenopausal osteoporosis. CONCLUSION: The study will offer high-quality and explicit evidence for applying GEG on the treatment of postmenopausal osteoporosis. OSF REGISTRATION: DOI 10.17605/OSF.IO/JCVBH.

Implementation of the policy protocol for management of surgical and non-surgical wounds in selected public health facilities in Ghana: An analytic case study.

BACKGROUND: It is estimated that millions of patients are affected by healthcare associated infections (HAIs) each year. In Ghana, high prevalence of HAIs in relation to non-surgical (also called contaminated wounds) and surgical wounds (also called sterile wounds) is largely attributed to poor adherence to policy protocols for wound management by frontline clinical staff especially nurses. OBJECTIVE: Investigate the extent to which nursing staff adhere to the policy protocol for management of non-surgical and surgical wounds in selected public health facilities in Ghana. METHODOLOGY: This is an analytic case study among nursing staff (n = 140) in three government facilities in the Volta region of Ghana. Subjective and objective performance scores of staff on adherence proxies were compared using the Wilcoxon Signed-rank test, and univariate ordered logistic regression analysis used to predict staff likelihood of adherence to policy protocols on non-surgical and surgical wound management. FINDINGS: Overall, staff self-rated themselves higher on subjective performance proxies relative to their objective scores (p<0.05). Staff with more years of work experience did not translate into a higher likelihood of adhering to standard protocol on wound management (Coef. = -0.49, CI = -0.93-0.05, p = 0.036). Being a senior nursing officer relative to lower nursing ranks increased staff likelihood of complying particularly with standard policy protocol for management of non-surgical wounds (Coef. 5.27, CI = 0.59 9.95, p = 0.027). CONCLUSION: There is the need for accelerated in-service training for staff on standard protocols for wound management coupled with supportive supervisions. Staff adherence to standard quality care protocols should be a pre-requisite for licensing of health facilities by regulatory bodies like Health Facilities Regulatory Agency and National Health Insurance Authority.

A comparison of two scar massage protocols in pediatric burn survivors.

The current evidence to support the use of massage for scar management is conflicting in the literature. The purpose of this study was to compare two scar massage protocols administered with pediatric burn survivors to determine if a more structured and standardized approach to scar massage could improve outcome. A retrospective review of the medical records of 100 children who received massage during the time period when two different protocols were implemented was conducted and data that was collected as part of the clinical exam regarding scar height, vascularity, pliability, itch and pain were extracted. Comparisons were made within subject for scar changes from baseline to follow up and between subjects receiving Protocol A and those receiving Protocol B for the same scar characteristics. Versions of the Vancouver Scar Scale were used to assess scars, while visual analogue scale, Itch Man Scale and Wong-Baker Faces Pain Scale were used to assess itch and pain. Results demonstrated improvements in itch and vascularity over time with both scar massage protocols. However, when comparing patients who received Protocol A to those who received Protocol B, there was no difference found in scar height, vascularity, pliability, itch or pain. Using commonly applied subjective scar assessment tools, we did not find clinically meaningful changes in scar characteristics with the implementation of a structured scar massage program compared to a general approach to massage. Further research is needed to better define the impact of massage on the recovery experience for burn survivors.

MinT-trial: Mindfulness versus cognitive behavioural therapy in Tinnitus patients: protocol for a randomised controlled, non-inferiority trial.

INTRODUCTION: Chronic subjective tinnitus is a condition that affects 5.1% to 42.7% of the population, depending on the definition and studied population. Evidence-based treatment options are limited. Cognitive Behavioural Therapy (CBT) has been proven effective to improve quality of life and to diminish tinnitus distress. Positive short-term effects of mindfulness-based interventions on tinnitus distress have been reported; however, the longer term effects remain to be studied. METHODS AND ANALYSIS: We designed a monocentre randomised controlled, non-inferiority trial to compare the effectiveness of mindfulness-based cognitive therapy (MBCT) and CBT in chronic tinnitus patients. Fifty-four patients (≥32 on the Tinnitus Functional Index (TFI), suffering from tinnitus for at least 6 months) will be included in the trial and randomised into one of two intervention groups. One group will receive MBCT, the other group will receive CBT. Our primary objective is to determine whether MBCT is non-inferior to (as good as) CBT on tinnitus distress (TFI) in chronic tinnitus patients at 12 months follow-up after end of therapy. Non-inferiority will be declared if the mean decrease in TFI score for MBCT is no worse than the mean decrease in TFI score in CBT, with statistical variability, with a margin of 13 points. Most secondary objectives (tinnitus severity of problem, tinnitus intrusiveness, quality of life, anxiety, depression, symptoms of psychopathology, perceived tinnitus complaints, coping style (mostly validated questionnaires)) are expected to show non-inferiority to MBCT compared with CBT. We expect a significant difference between MBCT and CBT for mindfulness awareness. ETHICS AND DISSEMINATION: This research protocol was approved by the Institutional Review Board of the UMC Utrecht (NL67838.041.18, V.4, April 2019). The trial results will be made accessible to the public in a peer-review journal. TRIAL REGISTRATION NUMBER: NL7745.

Clinical Practice Protocol of Creative Music Therapy for Preterm Infants and Their Parents in the Neonatal Intensive Care Unit.

Creative music therapy for preterm infants and their parents (CMT) has emerged as a promising family-integrated early intervention involving communicative musicality to improve infant development, parental well-being, and bonding. It aims at relaxing and nurturing the infant as well as promoting safety and social interaction for the parent-infant dyad. A music therapist specially trained in CMT hums or sings in an infant-directed, improvised, lullaby style continually adjusting to the individual needs, expressions, and breathing pattern of the preterm infant. Based on the principles of family-integrated care, the family is incorporated individually in the therapeutic process, namely by delivering CMT during kangaroo care (KC) and by motivating and facilitating parental vocal interaction with their infant to strengthen the parent-infant bonding. CMT aims at relaxing, stimulating, and coregulating premature infants at a time when many other interventions are still risky and can overwhelm the vulnerable patient group. CMT may be advantageous not by educating and teaching parents, but rather by uncovering the intuitive capacities of parenting that are often overshadowed by the traumatic experience of preterm birth. However, CMT can only be provided when the infants are clinically stable. CMT with parental integration is feasible when parents are available and receptive to participate. This paper presents a detailed protocol on how to use CMT to empower preterm infants and their families.

Implementation of a standardized nurse initiated protocol to manage severe hypertension in pregnancy.

Objectives: Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality, studies have shown that standardized protocols for treating severe hypertension improves outcomes. Our goal was to examine the effects of a protocol for treating severe hypertension.Methods: Using quality improvement methodology, we developed an evidence-based nurse-initiated protocol for management of severe hypertension. We used a before and after study design, with the primary outcome of time to administration of antihypertensive medications and time to achieve blood pressure control. Secondary outcomes included medication usage, time to repeat blood pressure, and proportion of women receiving appropriate treatment. Statistical analysis was completed with Stata, using data medians, 95% confidence intervals and a rank-sum test.Results: Data was collected for 5 months before and 5 months after protocol implementation, with 67 patients included before and 125 patients after implementation. The median time to treatment of severe range blood pressure decreased from 25 min before to 11 min after protocol implementation, p <.001. Twenty-four% of women were treated within 15 min before and 60.6% were treated within 15 min after protocol implementation. Median time required to regain sustained mild range blood pressure was reduced from 45 min before to 41 min after protocol implementation, p = .004. 67.5% of women regained mild range blood pressure within 60 min before and 81.9% achieved blood pressure control within 60 min after protocol implementation. These improved outcomes were evident within the first month after protocol implementation and remained stable throughout the follow-up period.Discussion: Implementation of an evidence-based nurse-initiated protocol for the treatment of severe hypertension in pregnancy decreases the time required to administer antihypertensive medication, time required to regain blood pressure control and nonbeneficial clinical variation. In addition, these benefits were achieved rapidly within a large hospital setting.

Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit.

OBJECTIVE: Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. DESIGN: A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. PATIENTS: Pediatric patients with congenital or acquired cardiac disease. SETTING: Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital. INTERVENTIONS: Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. RESULTS: There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). CONCLUSION: The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.

Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain.

OBJECTIVE: The purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain. METHODS: A steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds. RESULTS: The statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain. CONCLUSIONS: These best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process.

OBJECTIVE: The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities. METHODS: A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range. RESULTS: Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool. CONCLUSION: This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears.

BACKGROUND AND OBJECTIVES: Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS: We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS: A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION: The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Bacteriophage Application for Difficult-to-treat Musculoskeletal Infections: Development of a Standardized Multidisciplinary Treatment Protocol.

Bacteriophage therapy has recently attracted increased interest, particularly in difficult-to-treat infections. Although it is not a novel concept, standardized treatment guidelines are currently lacking. We present the first steps towards the establishment of a "multidisciplinary phage task force" (MPTF) and a standardized treatment pathway, based on our experience of four patients with severe musculoskeletal infections. After review of their medical history and current clinical status, a multidisciplinary team found four patients with musculoskeletal infections eligible for bacteriophage therapy within the scope of Article 37 of the Declaration of Helsinki. Treatment protocols were set up in collaboration with phage scientists and specialists. Based on the isolated pathogens, phage cocktails were selected and applied intraoperatively. A draining system allowed postoperative administration for a maximum of 10 days, 3 times per day. All patients received concomitant antibiotics and their clinical status was followed daily during phage therapy. No severe side-effects related to the phage application protocol were noted. After a single course of phage therapy with concomitant antibiotics, no recurrence of infection with the causative strains occurred, with follow-up periods ranging from 8 to 16 months. This study presents the successful outcome of bacteriophage therapy using a standardized treatment pathway for patients with severe musculoskeletal infection. A multidisciplinary team approach in the form of an MPTF is paramount in this process.

[Optimizing perioperative nutrition management in enhanced recovery after surgery].

As the concept of enhanced recovery after surgery (ERAS) have been widely promoted and applied in clinical practice,reasonable nutrition intervention strategy has been paid more and more attention. The whole-process nutrition management strategy has been optimized based on the ERAS concept,which mainly includes key points such as pre-operative nutrition screening and nutrition assessment,perioperative nutrition treatment,and post-discharge nutritional support. With more and more research evidences,the ERAS strategy would be more detailed and complete. Further nutrition-related high-quality researches is necessary to provide evidence support,aiming to establish a standardized,ERAS-optimized,whole-process nutrition management pathway.