Clinical and economic utility of a preterm birth predictor derived from an analysis of a large and diverse pregnancy cohort

Objective Evaluate clinical utility and cost effectiveness of identifying pregnancies at increased risk of preterm birth using a validated proteomic biomarker risk predictor to enable proactive intervention Study Design Pregnancies at elevated risk (≥15%) of preterm birth were identified in a cohort from TREETOP (NCT02787213), a study independent of biomarker development. In the screening arm, higher-risk subjects received simulated interventions based on published efficacy of multimodal treatment or care-management alone. Subjects in the non-screening arm received no interventions. Neonatal and maternal length of stay, neonatal mortality and morbidity and neonatal costs were compared between arms. Results Multimodal/care-management modeled treatments predicted reductions in neonatal (30%/22%) and maternal (9.2%/8.5%) hospital stays, neonatal morbidity and mortality (41%/29%), and neonatal costs (34%/16%) for the screening vs. non-screening arm. Conclusion Modeled interventions applied to pregnancies identified as higher-risk by a proteomic biomarker risk predictor demonstrate clinically and economically meaningful improvements in neonatal and maternal outcomes.

A Descriptive Study of Sports Chiropractors

BACKGROUND:This paper describes the education and case management profile of sports chiropractors with the Federation of International Sports Chiropractors (FICS) postgraduate qualification: International chiropractic sport science practitioner (ICSSP). The ICSSP is the predominant international sports chiropractic qualification.METHODS:A 39-item web-based survey examining practitioner, practice and clinical management characteristics was distributed via email to all sports chiropractors who hold an ICSSP (n = 240) in 2015. RESULTS:The survey response rate was 64% (n = 154). The average age of the chiropractors was 31-40 years, just over three quarters were male and have been in practice for 5-10 years. The majority of respondents were based in North America.Sports chiropractors treat a wide range of musculoskeletal conditions with multimodal care (active and passive) and treat professional, semi-professional and Olympic athletes. Sports chiropractors have referral and co-management relationships with a range of conventional and allied health providers.CONCLUSIONS: There is often a lack of knowledge and misinformation about the background of sports chiropractors. This study refutes a number of commonly held misbeliefs, and describes a workforce that is well educated, treat high-level athletes, utilise a multimodal approach to management, treat a wide variety of non-spinal musculoskeletal conditions, frequently prescribe rehabilitative exercise, and refer to and co-manage with other members of the sports medicine team.Trial registration: This study was approved by the RMIT University, SEH College Human Ethics Advisory Network (ASEHAPP 52-14 AMES)

Teleoncology: The Youngest Pillar of Oncology

The core pillars of multimodal care of patients with cancer are surgical, radiation, and medical oncology. The global pandemic of coronavirus disease 2019 (COVID-19) has suddenly resurrected a new pillar in oncology care: teleoncology. With oncologists reaching out to patients through telemedicine, it is possible to evaluate and fulfill patients’ needs; triage patients for elective procedures; screen them for influenza-like illness; provide them with guidance for hospital visits, if needed; and bridge oral medications and treatments when a hospital visit is not desirable because of any high risk-benefit ratio. Teleoncology can bring great reassurance to patients at times when reaching an oncology center is challenging, and more so in resource-constrained countries. Evidence-based treatment protocols, dispensable by teleoncology, already exist for many sites of cancer and they can provide a bridge to treatment when patients are unable to reach cancer centers for their standard treatment. The young pillar of teleoncology is going to remain much longer than COVID-19.

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

Background Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion. Methods We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay. Results Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches ( P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08). Discussion In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.

Conditions Associated with Worse Acceptance of a Simplified Accelerated Recovery after Surgery Protocol in Laparoscopic Colorectal Surgery: A Randomized Controlled Trial.

Background: Accelerated Recovery after Surgery Programs were initially applied to colorectal surgery and used a multimodal care approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the non-tolerance of patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery.Methods: 161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n=51) and those who did not (n=33), in order to analyze factors contributing to protocol nontolerance.Results: The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). The rates of complications and of returns to the emergency room were similar between groups. In the multivariate analysis of the subgroups, we found that prolonged surgical time, stoma creation, and the development of complications were variables that placed program acceptance at risk (p < 0.0001).Conclusions: The accelerated postoperative recovery program that was adopted, although simplified, was able to improve recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with program non-acceptance. Trial registration: Trial Registry: RBR2b4fyr - Date of registration: 03 October 2017.

Non-pharmacological Management of Soft Tissue Disorders of the Shoulder

Objective: To develop an evidence‐based clinical practice guideline for the non‐pharmacological management of shoulder soft tissue disorders (shoulder pain). Methods: This guideline is based on seven systematic reviews. A multidisciplinary expert panel formulated recommendations based on evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (through qualitative research). Target audience includes clinicians; target population is adults with shoulder pain (sprains/strains, tendinopathies). Recommendations: When managing shoulder pain, clinicians should rule out major pathologies, assess prognostic factors for delayed recovery, offer education and reassurance, and provide care in partnership with the patient. For shoulder pain ≤3 months’ duration, clinicians may consider cervicothoracic manipulation and mobilization as adjunct to usual care, thoracic manipulation, multimodal care (heat/cold, mobilization, exercise), or low-level-laser therapy. For shoulder pain >3 months’ duration, clinicians may consider exercise, laser acupuncture, low-level-laser therapy, general practitioner care, thoracic manipulation, cervicothoracic manipulation and mobilization with usual care, or multimodal care (combining heat/cold, mobilization, exercise). Clinicians should not offer cervical mobilization as adjunct to multimodal care, cervicothoracic manipulation and mobilization as adjunct to exercise, multimodal care (combining exercise, mobilization, taping, psychological intervention, massage), shockwave therapy, ultrasound, taping, interferential current, diacutaneous fibrolysis, or massage. For calcific tendinitis, clinicians may consider shockwave therapy. Clinicians should reassess at every visit and determine whether discharge or a referral is indicated. Public health impact/implications: Our guideline provides evidence-based recommendations intended to optimize patient care, reduce inefficient practices and healthcare costs, and improve health outcomes related to shoulder pain. Our recommendations help guide shared decision-making with patients, bridge the gap between research and practice, and reduce variation in care among clinicians. Our guideline identifies interventions that may provide some benefit, little effect, or potential harm to assist policymakers with decision-making at the population level. Overall, this guideline contributes to preventing and limiting the burden of musculoskeletal disability.

Maxillo-mandibular osteoradionecrosis following C-ion radiotherapy: Clinical notes and review of literature

Osteoradionecrosis (ORN) is one of the most feared complications after head and neck radiotherapy. Among head and neck sites, the mandible is the most commonly involved bone. Heavy ion radiotherapy delivers high-dose distribution focused to the target while simultaneously sparing of the adjacent organs but there are anyway some reported cases of ORN. Cases in literature reported well-known risk factors for its developing (e.g. tobacco and alcohol abuse, diabetes), but other are still debated (e.g. teeth extraction during radiotherapy). Prevention is mandatory but multimodal care may be required, tailoring all treatments on the patient needs. This study, after a brief revision of the literature, reports and a case of maxillo-mandibular ORN following carbon-ion (C-ion) radiotherapy and its treatment.

Review of multimodal treatment for type 2 diabetes: combining metabolic surgery and pharmacotherapy

Treating type 2 diabetes mellitus (T2DM) in patients with obesity remains a challenge for physicians, endocrinologists and surgeons, a fact supported by uncontroverted evidence from studies looking at mortality and associated morbidity. Metabolic surgery remains the most effective treatment for obesity and T2DM with evidence demonstrating an improvement or resolution of symptoms of T2DM and a reduction in a mortality and rates of cardiovascular events compared with pharmacotherapy alone. While these results are promising, two important limitations must be recognized and addressed. With regards to long-term remission of T2DM, the metabolic benefits of bariatric surgery appear to fatigue with time and a proportion of patients will not maintain normoglycaemia without pharmacotherapy. Second, there has been noteworthy progress in the development of several classes of medications for the treatment of T2DM which were unavailable when the original studies comparing the effects of bariatric surgery with pharmacotherapy were conducted. Recognizing the need for further treatment following metabolic surgery for long-term disease control in conjunction with the availability of newer medications offering more effective, nonsurgical treatment presents a critical turning point in treatment treating obesity. While the traditional approach would be to determine the superiority (or non-inferiority) of these agents compared with surgery, clinicians and surgeons must acknowledge the limitations of this attitude towards treatment given evidence from fields such as cancer, where a combinational approach is the gold standard. Recent advances in pharmacotherapy, present not only a novel approach to medical therapy but a renewed impetus to investigate what can be achieved through multimodal care.