MODERN DIAGNOSIS OF PLACENTAL DYSFUNCTION AND ITS COMPLICATIONS

The aim of the study was to improve the modern diagnosis of placental dysfunction and its complications. Materials and methods. The study involved a prospective survey of 70 pregnant women divided into the main group (pregnant women with placental dysfunction) (n = 50) and the control group (n = 20). The main group was divided into subgroups of pregnant women with placental dysfunction and fetal growth retardation (n = 30) and pregnant women with placental dysfunction without fetal growth retardation (n = 20). The control group comprised 20 pregnant women with physiological gestation. Apart from history taking, the study comprised obstetric and general clinical examination, evaluation of endothelium- dependent vasodilation, serum concentrations of soluble forms of vascular and platelet- endothelial molecules of cell adhesion 1, indicators of athrombogenicity of the vascular growth wall, uterine-placental-fetal blood circulation, pathomorphological and histometric examination of the placenta. Results. Based on the obtained clinical-morphological and endotheliotropic criteria, a personalized clinical algorithm for managing pregnant women with placental dysfunction was developed and implemented. Conclusions. Assessment of pregnancy results in a prospective clinical study showed that the proposed algorithm for personalization of the risk of perinatal abnormalities not only helped to avoid antenatal mortality, but also to prevent intranatal and early neonatal losses in patients with placental dysfunction and fetal growth retardation.

Non-Invasive and Surgical Modalities for Scar Management: A Clinical Algorithm

Scars can lead to aesthetic and functional impairments. The treatment of scars requires meticulous planning and an individually adapted therapeutic strategy. A conceptual algorithm for scar treatment makes everyday clinical work easier for the practitioner and offers more safety for the patient. Based on a retrospective analysis of 1427 patients who presented for treatment of a variety of scars, we developed an algorithm for scar management and treatment. The treatments are presented using case descriptions. Additionally, an electronic search of MEDLINE, EMBASE, and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for “scar treatment”, “hypertrophic scar treatment” and “keloid treatment”. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: conservative scar therapy, minimally invasive scar therapy, and surgical scar therapy using local, regional and free flaps. With this work, we provide an algorithm for safe scar treatment. For better understanding, we have described a clinical case for each algorithm modality.

Contemporary Algorithm for the Management of Hepatocellular Carcinoma in 2021: The Northwestern Approach

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and a major cause of cancer-related morbidity and mortality around the world. Frequently, concurrent liver dysfunction and variations in tumor burden make it difficult to design effective and standardized treatment pathways. Contemporary treatment guidelines designed for an era of personalized medicine should consider these features in a more clinically meaningful way to improve outcomes for patients across the HCC spectrum. Given the heterogeneity of HCC, we propose a detailed clinical algorithm for selecting optimal treatment using an evidence-based and practical approach, incorporating liver function, tumor burden, the extent of disease, and ultimate treatment intent, with the goal of individualizing clinical decision making.

A new scoring system and clinical algorithm for the management of suspected foreign body aspiration in children: a retrospective cohort study

Background Cases of foreign body aspiration in children may be encountered in emergency departments. A suggestive history is important in diagnosing aspirated foreign body owing to the difficulty in making a diagnosis on the basis of an abnormal physical examination or chest radiography alone. The aim of this study was to examine the sensitivity and specificity of the presenting symptoms, physical examination, and radiologic findings as predictors of foreign body aspiration in children. In addition, a feasible simple algorithm with a scoring system was generated to indicate bronchoscopic investigation. Methods In a retrospective cohort, medical records of patients aged less than 16 years with suspected foreign body aspiration who underwent flexible or rigid bronchoscopy were included. Data including age, sex, symptoms, physical examination findings, radiological features, nature and location of the foreign body, and outcome of the bronchoscopy were collected, and multivariable binary logistic regression analysis was employed for prediction of foreign body aspiration. Results A total of 203 children were included, and the model showed excellent discrimination power for positive foreign body aspiration (area under the curve = 0.911) with an accuracy, sensitivity, and specificity of 86.2, 90.6, and 76.6%, respectively. The total weighted risk score at a cut-off > 2 showed a significant good power of discrimination (area under the curve = 0.879), with a sensitivity of 79.9% and specificity of 84.4%. Accordingly, a clinical algorithm was recommended. Conclusions The proposed scoring system and clinical algorithm might help in decision making with regard to the need and type of bronchoscopy in children presenting with potential foreign body aspiration. However, further prospective multicenter studies should be conducted to validate this scoring system.

Diagnostic and Translational Utility of the Secondary Traumatic Stress Clinical Algorithm (STS-CA)

Objective: Current tools available to assess secondary traumatic stress (STS) do not account for whether the symptoms are functionally related to indirect trauma, determine functional impairment caused by the STS symptoms, and/or consider the duration of the disturbance. This prevents delineation of various expressions of traumatic stress related to indirect trauma that may constitute the phenomenon of STS. The STS Clinical Algorithm (STS-CA) was developed to make these distinctions, so that interventions can be tailored to need. This study investigates the following: (1) the diagnostic concordance between the STS-CA findings and scores on the Secondary Traumatic Stress Scale (STSS); (2) reasons for diagnostic discrepancies between the STS-CA and the STSS assessments. Method: Three trained interviewers used the STS-CA to guide the determination of clinical outcome ( N = 181) in a diverse group of helping professionals. Results: There was 100% agreement between the CAPS and the STS-CA, and fair agreement (κ =.426, p = .000) between the STS-CA and the STSS. The STS-CA demonstrated more sensitivity in classifying positive cases, and specificity in delineating those with atypical cluster presentations or little to no functional impairment that prohibited a post-traumatic stress disorder diagnosis than the STSS. Implications: Effective treatment of STS requires proper identification and the delivery of protocols that are tailored to the unique ways that STS manifests. This study provides some insights into the utility of the STS-CA in guiding this process and creates STS categories to organize and classify intervention strategies.

Focally administered succinate improves cerebral metabolism in traumatic brain injury patients with mitochondrial dysfunction

Following traumatic brain injury (TBI), raised cerebral lactate/pyruvate ratio (LPR) reflects impaired energy metabolism. Raised LPR correlates with poor outcome and mortality following TBI. We prospectively recruited patients with TBI requiring neurocritical care and multimodal monitoring, and utilised a tiered management protocol targeting LPR. We identified patients with persistent raised LPR despite adequate cerebral glucose and oxygen provision, which we clinically classified as cerebral ‘mitochondrial dysfunction’ (MD). In patients with TBI and MD, we administered disodium 2,3-13C2 succinate (12 mmol/L) by retrodialysis into the monitored region of the brain. We recovered 13C-labelled metabolites by microdialysis and utilised nuclear magnetic resonance spectroscopy (NMR) for identification and quantification. Of 33 patients with complete monitoring, 73% had MD at some point during monitoring. In 5 patients with multimodality-defined MD, succinate administration resulted in reduced LPR(−12%) and raised brain glucose(+17%). NMR of microdialysates demonstrated that the exogenous 13C-labelled succinate was metabolised intracellularly via the tricarboxylic acid cycle. By targeting LPR using a tiered clinical algorithm incorporating intracranial pressure, brain tissue oxygenation and microdialysis parameters, we identified MD in TBI patients requiring neurointensive care. In these, focal succinate administration improved energy metabolism, evidenced by reduction in LPR. Succinate merits further investigation for TBI therapy.

Clinical prediction rules for the diagnosis of neuritis in leprosy

Background Diagnosing neuritis in leprosy patients with neuropathic pain or chronic neuropathy remains challenging since no specific laboratory or neurophysiological marker is available. Methods In a cross-sectional study developed at a leprosy outpatient clinic in Rio de Janeiro, RJ, Brazil, 54 individuals complaining of neural pain (single or multiple sites) were classified into two groups (“neuropathic pain” or “neuritis”) by a neurological specialist in leprosy based on anamnesis together with clinical and electrophysiological examinations. A neurologist, blind to the pain diagnoses, interviewed and examined the participants using a standardized form that included clinical predictors, pain features, and neurological symptoms. The association between the clinical predictors and pain classifications was evaluated via the Pearson Chi-Square or Fisher’s exact test (p < 0.05). Results Six clinical algorithms were generated to evaluate sensitivity and specificity, with 95% confidence intervals, for clinical predictors statistically associated with neuritis. The most conclusive clinical algorithm was: pain onset at any time during the previous 90 days, or in association with the initiation of neurological symptoms during the prior 30-day period, necessarily associated with the worsening of pain upon movement and nerve palpation, with 94% of specificity and 35% of sensitivity. Conclusion This algorithm could help physicians confirm neuritis in leprosy patients with neural pain, particularly in primary health care units with no access to neurologists or electrophysiological tests.