Automated ankle brachial pressure index measurement devices to detect peripheral arterial disease in people with leg ulcers

Evidence-based recommendations on automated ankle brachial pressure index measurement devices to detect peripheral arterial disease in people with leg ulcers.

Hábitos saludables para prevenir heridas complejas en la extremidad inferior. Relevancia de recomendaciones según los expertos / Healthy habits to prevent complex lower extremity wounds. Relevance of the recommendations according to an experts

Introducción: Los programas educativos para la autocura dirigidos a personas que padecen patologías crónicas, producen una mejoría tanto en su salud como en su calidad de vida. Estos programas deben estar compuestos por consejos aceptados y validados. Objetivos: Determinar la relevancia de las recomendaciones para la prevención de heridas complejas publicadas por sociedades científicas que proporcionan los profesionales expertos en heridas; recopilar, clasificar según etiología y ordenar por relevancia estas recomendaciones. Metodología: Estudio observacional prospectivo con una encuesta a enfermeras/os expertas/os en heridas acreditados por el GNEAUPP. Se recogieron las recomendaciones publicadas por las sociedades científicas y se realizó una encuesta telemática para identificar el nivel de relevancia de estas. Variables: Años de experiencia en el tratamiento de heridas, ámbito laboral, puntuación de relevancia en una escala Likert para cada recomendación. Resultados: Participaron 40 enfermeras/os, el 88% tenía más de 5 años de experiencia y el 63%, más de 15 años. La mayoría, un 35%, desarrollaba su labor en atención primaria. Los resultados nos han permitido ordenar las recomendaciones para la autocura de las diferentes etiologías e identificar las más relevantes. Conclusiones: La identificación de las recomendaciones más relevantes permitirá focalizarnos en ellas para el programa educativo sobre hábitos saludables dirigido a los pacientes con úlceras de extremidad inferior llevado a cabo en nuestra Unidad Clínica de Heridas Complejas (AU)

Introduction: Self-care education programs for people suffering from chronic conditions improve both their health and their quality of life. These programs should be composed of accepted and validated advice. Objectives: To determine the relevance of recommendations for the prevention of complex wounds published by scientific societies and provided by professional experts in wounds; to compile, classify according to etiology and order by relevance these recommendations. Methodology: Prospective observational study with a survey of wound experts accredited by the GNEAUPP. The recommendations published by the scientific societies were collected and a telematic survey was carried out to identify their level of relevance. Variables: years of experience in wound management, work setting, relevance score on a Likert scale for each recommendation. Values collected in the data collection notebook were analyzed. Results: Forty nurses participated, 88% had more than 5 years of experience and 63% more than 15 years. Most of them, 35%, worked in primary care. The results have allowed us to order the recommendations for self-cure of the different etiologies and to identify the most relevant ones. Conclusions: The identification of the most relevant recommendations will allow us to focus on them for the educational program on healthy habits aimed at patients with lower extremity ulcers carried out in our Clinical Unit of Complex Wounds (AU)

Abordaje interdisciplinario de una persona con una úlcera venosa: Reporte de un caso clínico / Interdisciplinary approach of a person with a venous ulcer: Report of a clinical case

Las úlceras venosas son lesiones de piel de alta recurrencia localizadas en los miembros inferiores relacionadas con patologías venosas y con escasa tendencia a la cicatrización espontánea y alta probabilidad de reincidencia. Con el objetivo de visualizar la importancia que tiene para la persona usuaria el abordaje integral derivado del trabajo interdisciplinario de enfermería y terapia física en el manejo de lesiones venosas, se presenta el caso de una paciente de 85 años la cual fue abordada de manera interdisciplinaria en 4 sesiones durante cinco semanas, donde se realizó curación de la lesión y aplicación de terapia compresiva en conjunto con drenaje linfático manual, compresión neumática intermitente y prescripción de plan de ejercicios domiciliares. Adicionalmente, se realizaron sesiones de ejercicios presenciales 2 veces a la semana durante las mismas 5 semanas supervisadas por el profesional de terapia física, que favoreció la resolución de la lesión, mejorando así la calidad de vida de la usuaria.

Venous ulcers are highly recurrent skin lesions located in the lower limbs related to venous pathologies and with little tendency to spontaneous healing and high probability of recurrence. In order to visualize the importance for the user of the comprehensive approach derived from the interdisciplinary work of nursing and physical therapy in the management of venous leg ulcers, the case of an 85-year-old patient is presented who was approached by an interdisciplinary team of physical therapy and nursing in 4 sessions during five weeks, where the venous ulcer was healed and compression therapy was applied in conjunction with manual lymphatic drainage, compression intermittent pneumatics and prescription of home exercise plan. Additionally, face-to-face exercise sessions were carried out 2 times a week during the same 5 weeks, supervised by the physical therapy professional, which favored the resolution of the venous ulcer, thus improving the quality of life of the user. The interdisciplinary approach is highlighted as a central aspect in the evolution of the case.

Cooling Intervention (MUSTCOOL) for Prevention of Lower Extremity Ulcer Recurrence: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to test our MUSTCOOL cooling patch intervention on the incidence of venous leg (VLU) and diabetic foot ulcer (DFU) recurrence over a previously healed wound. DESIGN: A 6-month randomized controlled trial. SUBJECTS AND SETTING: The target population was individuals with previously healed ulcers receiving care in outpatient wound centers in the Southeastern region of the United States. The sample comprised 140 individuals with recently healed ulcers; their average age was 62.4 years (SD = 12 years); 86 (61.4%) were male; and 47 (33.6%) were Black or African American. METHODS: Participants were randomized to the MUSTCOOL or placebo patch. Both groups received instructions to apply the patch 3 times per week, and engage in standard of care including compression and leg elevation (VLU) or therapeutic footwear and hygiene (DFU). Demographic data were collected at baseline, and incidence measures taken at 1, 3, and 6 months. We also studied whether new ulcers developed on the adjacent leg or foot. Data were reported in frequencies/percentages. RESULTS: One hundred seventeen participants (84%) were analyzed who completed 6 months of study participation. Thirteen percent (9/69) and 17% (12/69) developed a recurrent or new VLU, respectively; 29% (14/48) and 13% (6/48) developed a recurrent or new DFU, respectively. One person in the DFU group developed both a recurrent and new ulcer. For 9 recurrent VLUs, 6 (66.7%) recurred in the MUSTCOOL group and 3 (33.3%) receiving the placebo. Of the 15 recurrent DFUs (includes individual who developed both a recurrent and new ulcer), 10 (66.7%) recurred in the MUSTCOOL group and 5 (33.3%) receiving the placebo. CONCLUSIONS: While the incidence of ulcer recurrent was slightly higher in the MUSTCOOL group, this finding was not considered clinically relevant. Overall ulcer recurrence during the 6-month study period was lower than reports in the literature, the time frame in which recurrence rates are highest. TRIAL REGISTRATION: The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156)-https://clinicaltrials.gov/ct2/show/NCT02626156.

Leg Ulcers in Sickle-Cell Disease: Treatment Update.

Significance: Sickle-cell leg ulcers (SCLUs) are a severe, chronic, and recurrent complication of sickle-cell disease (SCD). There are no official recommendations for treatment. Recent Advances: Only a few studies with a high level of evidence have been conducted to evaluate treatment of SCLUs. However, several studies have been conducted with a high level of evidence to evaluate the efficacy of treatments in venous leg ulcers, and SCLUs could benefit from these treatments, especially when a venous incompetence or an edema is associated. Pathophysiology of SCLUs includes a vasculopathy related to chronic hemolysis and an endothelial dysfunction, which could be therapeutic approaches to SCLU treatment. Critical Issues: Therapeutic approaches to SCLUs can target SCD on the one hand and skin healing and associated aggravating factors on the other. A review of the literature found only case series and six randomized controlled trials; some offered encouraging results, but most had serious biases. Clinical trials specifically targeting SCLUs are difficult to realize because of the small number of affected patients, in comparison with patients with leg ulcers from other causes. Future Direction: Treating SCLUs remains a challenge. Data in the literature are currently insufficient to offer clear treatment guidelines because of several biases in controlled studies. New studies are under way to assess the efficacy of topical treatments and describe the microbiome of SCLUs. Prevention of SCLU recurrence should be assessed in future clinical trials because the high risk of recurrence is an unsolved critical issue.

Paciente con úlceras vasculares infectadas. Un abordaje desde la teoría de Dorothea Orem / A patient with infected vascular ulcers: An approach based on Dorothea Orem's Theory

La úlcera vascular es muy dolorosa por lo que suele ir acompañada por dificultad en la movilidad y disminución de la calidad de vida. Por ello es fundamental una correcta curación de las úlceras junto con un adecuado manejo del dolor y llevar a cabo prevención de caídas. Se expone el caso de un varón de 71 años que presenta cuatro úlceras vasculares infectadas en miembros inferiores. Para el abordaje del caso clínico se ha realizado la valoración enfermera según la teoría del déficit de autocuidado de Dorothea Orem, se han utilizado las taxonomías de lenguaje enfermero NANDA, NIC y NOC, y se ha aplicado el modelo AREA de Pesut. Se identificaron los diagnósticos enfermeros de Intolerancia a la actividad y Riesgo de caídas; y como problemas de colaboración las úlceras vasculares, la infección de las úlceras vasculares y el dolor agudo. Los resultados (NOC) planteados fueron: "Curación de la herida: por segunda intención", "Tolerancia a la actividad" y "Movilidad". Las intervenciones (NIC) desarrolladas fueron: "Cuidados de las heridas", "Terapia de ejercicios (ambulación), "Manejo ambiental (seguridad)", "Administración de medicación (antibióticos): intravenosa" y "Manejo del dolor: agudo". Tras una semana de aplicación del plan de cuidados se consiguió la regresión completa de la infección de las úlceras y una buena evolución de las lesiones cutáneas

Vascular ulcers are very painful, and they usually entail mobility difficulties and a reduction in quality of life. Therefore, the correct cure of ulcers, together with an adequate pain management, and conducting the prevention of falls are essential. The case of a 71-year-old male is presented, with four infected vascular ulcers in lower limbs. For this clinical case approach, a nursing assessment has been conducted according to Dorothea Orem's Self-Care Deficit Nursing Theory, using the NANDA, NIC and NOC taxonomy, and applying the Pesut's AREA model. The Activity Intolerance and Risk of Falls nursing diagnoses were identified; and as collaboration problems: vascular ulcers, vascular ulcer infection, and acute pain. The (NOC) outcomes raised were: "Wound Healing: Secondary Intention", "Activity Tolerance" and "Mobility". The (NIC) interventions conducted were: "Wound Care", "Exercise Therapy (Ambulation)", "Environmental Management (safety); "Medication Administration (antibiotics): Intravenous", and "Acute Pain Management". After one week of implementing the care plan, complete regression of ulcer infections was achieved, as well as good evolution of skin lesions

Implementation of NICE technology guidance on venous leg ulcers and diabetic foot ulcers: a conference report.

Implementation of evidence-based care is central to achieving good results. In the UK, this involves implementing guidance from the National Institute for Health and Care Excellence (NICE). Here, Tracy Cowan, JWC consultant editor, reports on a conference that outlined recently published NICE guidance on UrgoStart for treating leg ulcers and diabetic foot ulcers, and described how to incorporate this into everyday practice to drive significant cost savings and improve patient outcomes.

Skin considerations for older adults with wounds.

Ageing leads to a number of skin changes that not only place an older adult at risk of tissue damage, but can present as peri-wound problems for those with existing wounds, for example, incontinence-associated and moisture-associated dermatitis in individuals with pressure ulcers. Older adults with venous disease experience skin changes concomitant with venous hypertension, making the skin more at risk of breakdown, specifically the common complications of lipodermatosclerosis and venous eczema. In individuals with diabetic foot disease, skin changes related to autonomic neuropathy mean patients can experience dry skin that cracks easily, placing them at higher risk of infection. Common to all individuals with wounds requiring some sort of dressing is the risk of medical adhesive-related skin injury, where dressing application and removal need to be of the utmost priority to reduce the risk of injury. This article discusses some of the common peri-wound skin considerations in patients with chronic wounds.

Compression Stockings for the Prevention of Venous Leg Ulcer Recurrence: A Health Technology Assessment.

BACKGROUND: People with chronic venous insufficiency who develop leg ulcers face a difficult condition to treat. Venous leg ulcers may persist for long periods of time and have a negative impact on quality of life. Treatment requires frequent health care provider visits, creating a substantial burden across health care settings.The objective of this health technology assessment was to evaluate the effectiveness, safety, cost-effectiveness, budget impact, and patient experiences of compression stockings for prevention of venous leg ulcer recurrence. METHODS: We conducted a systematic review of the literature to identify randomized trials and observational studies examining the effectiveness of compression stockings in reducing the risk of recurrence of venous leg ulcers after healing and/or reported on the quality of life for patients and any adverse events from the wearing of compression stockings. We performed a literature search to identify studies and evaluated the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.We conducted a cost-utility analysis with a 5-year time horizon from the perspective of the Ontario Ministry of Health and Long-Term Care. We compared compression stockings to usual care (no compression stockings) and simulated a hypothetical cohort of 65-year-old patients with healed venous ulcers, using a Markov model. Model input parameters were obtained primarily from the published literature. In addition, we used Ontario costing sources and consultation with clinical experts. We estimated quality-adjusted life years gained and direct medical costs. We conducted sensitivity analyses and a budget impact analysis to estimate the additional costs required to publicly fund compression stockings in Ontario. All costs are presented in 2018 Canadian dollars.We spoke to people who recently began using compression stockings and those who have used them for many years to gain an understanding of their day-to-day experience with the management of chronic venous insufficiency and compression stockings. RESULTS: One randomized controlled trial reported that the recurrence rate was significantly lower at 12 months in people who were assigned to the compression stocking group compared with people assigned to the control group (risk ratio 0.43, 95% CI, 0.27-0.69; P = .001) (GRADE: Moderate). Three randomized controlled trials reported no significant difference in recurrence rates between the levels of pressure. One randomized controlled trial also reported that the risk of recurrence was six times higher in those who did not adhere to compression stockings than in those who did adhere. One single-arm cohort study showed that the recurrence rate was considerably higher in people who did not adhere or had poor adherence (79%) compared with those who adhered to compression stockings (4%).Compared with usual care, compression stockings were associated with higher costs and with increased quality-adjusted life years. We estimated that, on average, the incremental cost-effectiveness ratio of compression stockings was $27,300 per quality-adjusted life year gained compared to no compression stockings. There was some uncertainty in our results, but most simulations (> 70%) showed that the incremental cost-effectiveness ratio remained below $50,000 per quality-adjusted life-year. We estimated that the annual budget impact of funding compression stockings would range between $0.95 million and $3.19 million per year over the next five years.People interviewed commonly reported that chronic venous insufficiency had a substantial impact on their day-to-day lives. There were social impacts from the difficulty or inability to walk and emotional impacts from the loss of independence and fear of ulcer recurrence. There were barriers to the wearing of compression stockings, including replacement cost and the difficulty of putting them on; however, most people interviewed reported that using compression stockings improved their condition and their quality of life. CONCLUSIONS: The available evidence shows that, compared with usual care, compression stockings are effective in preventing venous leg ulcer recurrence and likely to be cost-effective. In people with a healed venous leg ulcer, wearing compression stockings helps to reduce the risk of recurrence by about half. Publicly funding compression stockings for people with venous leg ulcers would result in additional costs to the Ontario health care system over the next 5 years. Despite concerns about cost and the daily chore of wearing compression stockings, most people interviewed felt that compression stockings provided important benefits through reduction of swelling and prevention of recurrence.

Conocimiento enfermero sobre prevención, diagnóstico y cuidados de las úlceras de extremidad inferior en un área sanitaria / Nursing knowledge about prevention, diagnosis and care of lower extremity ulcers in a Health Area

Objetivo: Determinar el grado de conocimiento de recomendaciones basadas en la evidencia sobre cuidados de úlceras de extremidad inferior (UEI) que tratan las enfermeras que trabajan en el Área Sanitaria de Ferrol. Analizar su relación con la formación continuada. Metodología: Estudio descriptivo, transversal y observacional mediante cuestionario diseñado ad hoc entre mayo y junio de 2015. La población de estudio la constituyeron enfermeras que trabajaban en hospital, atención primaria o centro sociosanitario que posea concierto en suministro de productos de cura en ambiente húmedo. Se obtiene autorización del CEIC de Galicia. Resultados: Participaron 205 enfermeras (66% de la población a estudio). Un 62% ha realizado algún curso de formación sobre UEI en los últimos 5 años. Todas manifiestan que se debe tener en cuenta la calidad de vida de estos pacientes; un 5,9% utiliza la herramienta validada para su valoración. El 94,1% considera útil una "app" sobre UEI en algún dispositivo electrónico. Las variables con capacidad independiente para predecir el conocimiento sobre UEI son conocer las guías de práctica clínica, saber calcular el índice tobillo-brazo y los valores para detectar claudicación intermitente; esta última es la más decisiva. Conclusiones: A pesar de la formación recibida, existen áreas en las que es necesario incidir. Mejorar su capacitación es imprescindible para asegurar la calidad en la atención de las personas que las padecen. Se objetiva la necesidad sentida de los profesionales respecto a la creación de una aplicación como herramienta de ayuda en la toma de decisiones

Aim: Determine the degree of knowledge about recommendations based on care evidence, of lower-extremity ulcers by nurses working in the Health Area of Ferrol. Analyze the relationship with continuous training. Methods: Descriptive, cross-sectional and observational study through a questionnaire designed ad hoc between May and June 2015. The study population were nurses that worked in the Hospital, Primary Care and Socio-Health Center that had a concert in products supply of wound healing in humid environment. The study has been approved by the Clinical Research Ethics Committee of Galicia. Results: 205 nurses have participated (66% of the population to study). 62% have done a training course of leg ulcers for the last 5 years. All of them shows that the quality of life of these patients must be considered; 5.9% use the validated tool for their assessment. 94.1% consider useful an app of leg ulcer in some electronic device. The variables with independent ability to predict the knowledge about LowerExtremity Ulcers are know the clinical practice guidelines, know how to calculate the Arm-Ankle Index and the values to detect intermittent claudication, being the last one the most decisive. Conclusions: Despite the training received there are areas in which it is necessary to influence. Improving their training is essential to ensure the quality of care for people who suffer from them. The felt need of the professionals regarding the creation of an application as a help tool in making decisions is objectified

Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines.

INTRODUCTION: The adequate use of compression in venous leg ulcer treatment is equally important to patients as well as clinicians. Currently, there is a lack of clarity on contraindications, risk factors, adverse events and complications, when applying compression therapy for venous leg ulcer patients. METHODS: The project aimed to optimize prevention, treatment and maintenance approaches by recognizing contraindications, risk factors, adverse events and complications, when applying compression therapy for venous leg ulcer patients. A literature review was conducted of current guidelines on venous leg ulcer prevention, management and maintenance. RESULTS: Searches took place from 29th February 2016 to 30th April 2016 and were prospectively limited to publications in the English and German languages and publication dates were between January 2009 and April 2016. Twenty Guidelines, clinical pathways and consensus papers on compression therapy for venous leg ulcer treatment and for venous disease, were included. Guidelines agreed on the following absolute contraindications: Arterial occlusive disease, heart failure and ankle brachial pressure index (ABPI) <0.5, but gave conflicting recommendations on relative contraindications, risks and adverse events. Moreover definitions were unclear and not consistent. CONCLUSIONS: Evidence-based guidance is needed to inform clinicians on risk factor, adverse effects, complications and contraindications. ABPI values need to be specified and details should be given on the type of compression that is safe to use. Ongoing research challenges the present recommendations, shifting some contraindications into a list of potential indications. Complications of compression can be prevented when adequate assessment is performed and clinicians are skilled in applying compression.

Quality of life of elderly patients with leg ulcers / Calidad de vida de pacientes ancianos con úlceras en las piernas / Qualidade de vida de idosos com úlceras de perna

Abstract Objectives: To identify compromised domains of the 36-Item Short Form Survey (SF-36) for elderly individuals with leg ulcers and correlate their clinical and sociodemographic variables with the SF-36's components. Method: Exploratory and cross-sectional study conducted with 50 elderly individuals with leg ulcers. The instruments were the sociodemographic and clinical form and the SF-36. The Statistical Package for the Social Sciences was used to analyze data. Results: Most were married, retired, and received one times the minimum wage, were Caucasians or of mixed race, and had hypertension. In regard to the SF-36, the most compromised domain was physical limitations, while social aspects and general health status were the less compromised domains. The SF-36 domains were not correlated with age, income, duration or size of the lesion or pain. Conclusion: The ulcer-related biopsychosocial aspects need to be considered in order to devise more effective nursing interventions.

Resumen Objetivos: Identificar las zonas afectadas de la Escala de Calidad de Vida (SF-36) en ancianos con úlceras en las piernas y correlacionar las variables clínicas y sociodemográficas de los ancianos con los componentes del SF-36. Método: Investigación exploratoria y transversal realizado con 50 ancianos con úlceras en las piernas. Los instrumentos utilizados fueron: datos forman sociodemográfico y clínico y SF-36. Para el análisis de datos se utilizó el paquete estadístico para las Ciencias Sociales. Resultados: Se observó un predominio de ancianos casados, se retiró con el salario mínimo, blanco y marrón, hipertenso. En relación a SF-36, los pacientes fueron los más afectados cuanto a la Limitación de los Aspectos Físicos y menos perjudicados los Aspectos Sociales y de Salud. Los dominios del SF-36 no se correlacionaron con edad, ingresos, tiempo y tamaño de la lesión y dolor. Conclusión: Es necesario tener en cuenta los aspectos biopsicosociales relacionados con lesiones para el desarrollo de intervenciones de enfermería más eficaces.

Resumo Objetivos: Identificar os domínios da Escala de Qualidade de Vida (SF-36) prejudicados nos idosos com úlceras de perna e correlacionar as variáveis clínicas e sociodemográficas dos idosos com os componentes da SF-36. Método: Pesquisa quantitativa, exploratória, transversal realizada com 50 idosos com úlceras de perna. Os instrumentos utilizados foram: formulário de dados sociodemográficos e clínicos e a SF-36. Para análise dos dados, foi utilizado o Statistical Package for the Social Science. Resultados: Predomínio de idosos casados, aposentados com salário mínimo, brancos e pardos, hipertensos. Em relação à SF-36, os participantes estiveram mais prejudicados, no que se refere à limitação por aspectos físicos e menos prejudicados, nos aspectos sociais e no Estado Geral da Saúde. Os domínios da SF-36 não estiveram correlacionados a idade, renda, tempo e tamanho da lesão e dor. Conclusão: É necessário considerar os aspectos biopsicossociais relacionados à lesão para a elaboração de intervenções de enfermagem mais efetivas.

[Compression therapy: Choosing the right option for leg ulcers in 2016]. / Quelle compression veineuse utiliser en 2016 pour un ulcère de jambe ?

Compression therapy is a mandatory treatment of leg ulcers whether the goal is cure (stage C6 in the international classification for chronic venous disease) or prevention of recurrence (stage C5). Different indications for compression therapy were proposed by the French Superior Health Authority (HAS) in 2010, but new studies have modified attitudes since that time. Considering the very large number of options available, the many co-morbid conditions observed in these patients, as well as patient age and available assistance, it is important to adapt to the variable clinical and social situations encountered. One must keep in mind that a well-controlled treatment should improve trophic disorders and patient comfort. A poorly-adapted treatment with little or even deleterious effect will be abandoned by the patient.

Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care Across the Continuum.

Chronic venous insufficiency is a prevalent disease that frequently leads to development of venous leg ulcers. While a number of evidence-based clinical practice guidelines have been developed that provide guidance for clinicians when caring for patients with chronic venous insufficiency, they lack adequate detail concerning selection and application of compression for prevention and management of venous leg ulcers. In order to address this need, the WOCN Society appointed a task force to develop an algorithm for compression for primary prevention, treatment, and prevention of recurrent venous leg ulcers in persons with chronic venous insufficiency. The task force used findings from a scoping literature review to identify current best evidence needed to support decision points and pathways within the algorithm. In addition, the task force convened a panel of 20 clinicians and researchers with expertise in lower extremity venous disorders in order to establish consensus around pathways and decision points within the algorithm lacking robust evidence. Following initial construction of the algorithm, a second interdisciplinary group of expert clinicians established content validity and provided additional qualitative feedback used to complete final revisions of the algorithm. This article reviews the process used to create this landmark algorithm, including generation of the evidence- and consensus-based statements used in its construction, the various pathways, and rich supplemental materials embedded within the algorithm, and the process used to establish content validity.