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This pilot survey aimed to explore the feasibility of conducting a nationwide survey investigating the current practice and attitudes towards complementary and alternative medicine (CAM) in New Zealand registered physiotherapists. This was a cross-sectional, online study using a questionnaire developed from previous survey instruments. An electronic link to the questionnaire was distributed via email to members of the Otago Branch of Physiotherapy New Zealand (n = 344). Questions included current clinical practice and use of CAM as well as attitudes and opinions on its effectiveness. Feasibility outcomes of this survey included the response rate and completion rate. Data were analysed in Microsoft Excel®. The response rate was 10.5% (n = 36) and the completion rate was 86.1% (n = 31/36). A range of conditions treated with CAM were cited by respondents; the most frequently treated condition was “back and neck pain” (n = 10/36). Physiotherapists in this sample believed acupuncture and massage are the most effective CAM modalities used for “back and neck pain” treatment and were most likely to use acupuncture and massage as CAM modalities when treating these conditions. Acupuncture was found to be the most common CAM practiced by respondents, and an acupuncturist was the CAM practitioner to which patients are most commonly referred by respondents. This study demonstrated that conducting a nationwide survey is feasible, subject to an improved survey design and increased response rate.

Percutaneous sacroiliac screw is one of the main methods to treat unstable posterior pelvic ring injury. However, complexity of pelvic anatomical structure increases the difficulty and risk with freehand operation. Besides, S2 screw fixation began to receive attention. The purpose of the current study was to evaluate the safety, accuracy, efficiency and clinical outcome of robot-assisted S2 screw fixation for posterior pelvic ring injury.We reviewed 128 cases of unstable posterior pelvic ring injury treated by percutaneous sacroiliac screw fixation in our hospital from January 2016 to January 2020. All cases were divided into robot-assisted S1 group (RAS1), robot-assisted S2 group (RAS2), freehand group S1 group (FHS1) and freehand group S2 group (FHS2). The mean times of fluoroscopy per screw and adjustment per guide wire were used to evaluate radiation exposure and the efficiency of screw placement, respectively. The final position of the screw was evaluated with postoperative CT to illustrate security and accuracy. 108 patients (84.38%) were followed up for 5~24 months and the Majeed scores were compared among groups.A total of 180 screws were inserted. In comparison of the mean times of fluoroscopy per screw and adjustment per guide wire, RA group was significant less than FH group, further comparison revealed that freehand S2 placement need more fluoroscopy and adjustment times compared with freehand S1 placement, but for robot-assisted procedure, there was no difference between placing S1 and S2. Screw penetration was found in the FHS1(3/48) and FHS2(2/14) and none in RAS1 or RAS2, which means robot-assisted groups were more safety and accurate (P0.001). The mean Majeed score in RAS1 (83.33±13.47) and RAS2 (82.32±11.42) was higher than in FHS1 (80.43±12.25) and FHS2 (75.08±18.47), but this difference failed to reach significant.Compared with the freehand operation, TiRobot increased the safety and accuracy, reduced radiation exposure, and improved the efficiency. TiRobot could reduce the risk of S2 placement and provide a safe and feasible way for clinical practice.

Partial nerve recovery either after expectant observation following an injury in-continuity or after nerve repair is not an uncommon occurrence. Historically, treatment strategies in these situations—late repair, revision repair, or acceptance of a mediocre result—were unsatisfying. The reverse end-to-side, or supercharging, nerve transfer was conceived to offer a more palatable option. Partially validated primarily through small animal research, supercharging has been rapidly translated to clinical practice. Many have extended the indications beyond the original intent, though the final place of this technique in the peripheral nerve surgeon’s armamentarium is still yet to be determined.

Eating disorder and weight loss interventions have typically been regarded as distinct or antithetical, despite a growing number of individuals with comorbid eating pathology and obesity. This siloing of research and practice has created a clinical conundrum for providers seeking to treat individuals with an eating disorder seeking to lose weight (e.g., required pre-surgical weight loss). To date, integrated treatment research targeting both eating disorders and weight loss is rare and practical guidance is lacking, especially for restrictive/binge-purge subtypes. This case example describes how an integrated approach was applied within a naturalistic outpatient clinical practice setting to successfully treat a client presenting with excess weight and severe bulimia nervosa who was medically required to lose weight for orthopedic surgery. We conclude by reviewing the benefits and challenges of integrating eating disorder and behavioral weight loss treatments and providing practical insights for treatment providers.

International Dermatology Outcome Measures and the American Academy of Dermatology recently agreed on a physician-reported global severity measure to demonstrate quality of care in inflammatory dermatoses.Because patient-reported outcome measures are also important, we aimed to achieve consensus on 1 of these measures for clinical practice.Patients and providers participated in a consensus-building study involving a modified-Delphi technique. Voting was focused on identifying a minimal set of assessments for clinical practice, patient global assessments (PtGAs), Skindex instruments, and final instrument selection for quality improvement.Among 53 stakeholders,70% agreed that identification of patient goals, assessment of treatment harm, and assessment of the adequacy of treatment response were the minimal assessments needed for clinical practice. The most preferred PtGA was a 5-point PtGA (scale 0-4; 0 = clear, 4 = severe) having an optional check-box for worst ever. A new metric to assess change since treatment initiation, which we called a trajectory measure, was proposed. Stakeholders preferred Skindex instruments over PtGAs and a trajectory measure for clinical practice.A small number of patients and caregivers were involved and a consensus was not reached on all items.PtGAs as standalone measures do not adequately capture the patient's assessment of disease severity or the effect of care. The combination of a PtGA with a Skindex instrument or another measure of health-related quality of life might provide a more comprehensive evaluation of patients in clinical practice.

Objective: To assess the diagnostic agreement between smartphone-enabled otoscopy and rigid otoendoscopy in tympanic membrane and middle ear diseases. Methods: A cross-sectional study was carried out to analyze otoscopies in patients seen at a general otorhinolaryngology (ORL) outpatient clinic, from June to December 2019. Eighty-three images of patients obtained from otoscopies performed through a smartphone device and a rigid endoscope were included, recorded, and stored for further analysis. The images were first analyzed by an experienced otologist, who assigned his diagnostic impression (defined as the gold standard) on each of the images. After this analysis, the images were displayed to a group of secondary raters (an experienced otorhinolaryngologist, a second-year resident in ORL, and a general practitioner). A questionnaire was applied related to each image. Results: There was high agreement between the smartphone device and the otoendoscopy images for all professionals, with a Kappa coefficient of 0.97 (p < 0.001). The smartphone device showed a diagnostic sensitivity of 81.1% and a specificity of 71.1%. As for the otoendoscopy, it showed a sensitivity of 84.7% and a specificity of 72.4%. The image classification as “2 = Good” was the most frequent one, with 34.9% for otoendoscopy and 31.6% for the smartphone device. Conclusion: There was a high diagnostic agreement between smartphone device-guided otoscopy and the rigid otoendoscopy, demonstrating the feasibility of using this device in clinical practice. Level of Evidence: 3

Objective To compare the incidence of endophthalmitis after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections with and without patient face masking. Design Two-centre retrospective cohort study Participants Patients receiving a total of 28 501 injections (period 1 before masking: n = 13 863; period 2 after masking: n = 14 638) Methods Periods before and after implementation of patient masking were compared: period 1 (July–December 2019) and period 2 (July–December 2020). All patients requiring treatment for endophthalmitis following intravitreal anti-VEGF injections were reviewed. Endophthalmitis risks were compared. Statistical simulations were run to determine the number of injections or endophthalmitis cases required to detect a statistically significant difference between both periods. Results Five patients (0.036%) had endophthalmitis in period 1 compared with 7 patients (0.048%) in period 2. Odds ratio, 95% confidence interval, for risk of patient masking was 1.326, 0.421–4.179 (p = 0.63). Three patients (0.022%) in period 1 had culture-positive endophthalmitis compared with 2 patients (0.014%) in period 2. Risk of patient masking for culture-positive endophthalmitis was 0.631, 0.105–3.779 (p = 0.61). Assuming similar rates of endophthalmitis, 476,806 injections in both groups would be required to detect a significant difference. Alternatively, assuming that masking would increase endophthalmitis risk in period 2, a significant difference would require twice as many cases (n = 15, 0.102%) for a risk of 2.843, 1.033–7.825 (p = 0.043). Conclusions The implementation of patient masking in clinical practice did not significantly alter the rate of endophthalmitis following intravitreal anti-VEGF injections.

Background Most surgeons are unaware that idiopathic neuropathy, which occurs independently of mechanical injury, can present as postoperative peripheral neuropathy. The aim of this study was to reveal the presence of postoperative neuropathy considered to be induced by surgical stress and to make surgeons aware that idiopathic neuropathy can occur postoperatively. Methods We conducted a survey among orthopedic surgeons regarding patients with postoperative neuropathies of unknown cause. For each case, the type of neuropathy, preceding surgery and anesthesia, patient background, clinical findings, and clinical course were investigated. Results Seven patients were identified. The mean time from surgery to the onset of neuropathy was 9.3 days (range 1–15 days). Five of the patients fully recovered spontaneously within 1 year, while the remaining two underwent neurolysis. One patient presented with hourglass-like constrictions in the radial nerve. No inflammatory cells were found in the epineurium of the affected nerve. Conclusions Although it is rare, postoperative idiopathic neuropathy occurs in clinical practice, and it is crucial that surgeons recognize the existence of this neuropathy to elucidate its pathogenesis as well as to reduce the risk of litigation.

Purpose: To examine and critique international clinical practice guidelines (CPGs) related to transgender and gender diverse children and youth and to assess the applicability of the guidelines to ...

The recording of 12 lead electrocardiograms (ECG) is one of the most useful and commonly performed medical procedures. ECGs are used in diagnosis, risk-stratification management decision-making, and assessment in response to therapy. The correct interpretation of 12 lead ECG recordings is complex and clinically challenging with misinterpretation having the potential to result in poor outcomes or even patient fatality. Despite its widespread use, several studies have highlighted deficiencies in ECG interpretation skills among health professionals. The literature suggests that up to 33% of ECG interpretations have some error when compared to the expert reference and up to 11% resulted in inappropriate management. The pedagogy of ECG interpretation lacks universal establishment; time allocation, faculty training and teaching format vary considerably within the literature. This review of the literature reports how a lack of established ECG reporting methods may contribute to the variation in reported ECG interpretation competence across many healthcare professionals. The ubiquity of the ECG in clinical practice and an over reliance on computer assisted ECG interpretation are additionally explored as factors affecting acquisition and retention of this clinical skill.

Introduction Although several combination therapies for acute myeloid leukemia (AML) have emerged recently, there has been a lack of published surveys and educational projects focused on these important treatment options. We aimed to improve the oncology team members’ knowledge and awareness of several FDA approved combination therapies for AML, including glasdegib (DAURISMO®), venetoclax (VENCLEXTA®), GO (MYOLOTARG®),CPX-351 (VYXEOS®), and midostaurin (RYDAPT®). Additionally, we aimed to examine these teams’ perspectives, views, and attitudes towards these topics and finally identify barriers to the implementationof such therapies in clinical practice. Method Initially, we developed booklets and then distributed them to each participating oncology and hematology office. Subsequently, all participating oncology and hematology team members were asked to complete an anonymous online survey to test their knowledge of and attitudes toward the subjects. Main results There was a total of 52 survey respondents. The correct answer regarding various combination therapies for AML was identified by nearly 70% or more of survey takers. The level of awareness of project subjects significantly improved after reading our printing materials. Many survey respondents were motivated to learn more about combination therapies for AML as well as discuss these topics with others. Conclusions Our booklets effectively improved understanding and awareness of combination therapies for AML. Future studies should explore awareness, knowledge, and perception of other new and emerging combination therapies for AML among oncology and hematology team members in other areas.

Hypertrophic cardiomyopathy is a complex disease with significant implications for patients and the physicians called upon to care for them during the perioperative period. In this article, the 2020 American Heart Association and American College of Cardiology clinical practice guidelines for the evaluation and management of pediatric and adult patients with hypertrophic cardiomyopathy are reviewed, with a particular focus on perioperative considerations for the anesthesiologist.

Objective Several clinical practice guidelines have been produced and disseminated for the evaluation of a neck mass. However, to date, the quality and methodologic rigor of these clinical practice guidelines have not been appraised. Therefore, this study set out to identify and assess the methodologic quality of national and international guidelines for the evaluation and management of neck masses in adults. Methods We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources until September 2020. The quality of these guidelines was assessed by four reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered acceptable quality if they scored >60%, and Intraclass Correlation Coefficients (ICC) were calculated to assess agreement among the appraisers. Results Seven guidelines were assessed for evaluation. Among these, only the American Academy of Otolaryngology (AAO), Cancer Care Manitoba (CCMB), and the American Society of Clinical Oncology (ASCO) achieved an overall rating of “high”. The remaining four guidelines achieved ratings of either “average” or “low”. The “Scope and Purpose” domain achieved the highest mean score (94.4% ± 5.0%), and lowest was “Applicability” (51.5% ± 29.2%). ICC analysis showed substantial to very good agreement across all domains (0.75–0.98). Conclusion These findings highlight the variability in methodologic quality of guidelines for the evaluation and management of adult neck mass. The results from this analysis highlight the need to improve guidelines development process for this topic and may guide the selection and use of these guidelines in clinical practice.

BACKGROUND AND AIMS The use of forceps for removal of non-diminutive polyps is associated with incomplete resection compared to snare polypectomy. However, few studies have characterized the frequency of forceps polypectomy for non-diminutive polyps or identified strategies to improve this practice. To address this gap, we estimated prevalence and predictors of forceps polypectomy in clinical practice and examined the effectiveness of a multi-component intervention to reduce inappropriate forceps polypectomy. METHODS We retrospectively reviewed all colonoscopies with polypectomies performed at two U.S. health systems between 10/1/2017 and 9/30/2019. We used a mixed-effects logistic regression model to examine the effect of a multi-component intervention, including provider education and a financial incentive, to reduce inappropriate forceps polypectomy, defined as use of forceps polypectomy for polyps ≥5mm. RESULTS A total of 9968 colonoscopies with 25534 polypectomies were performed by 42 gastroenterologists during the study period. Overall, 8.5% (n=2176) of polyps were removed with inappropriate forceps polypectomy. Inappropriate forceps polypectomy significantly decreased after the intervention (OR 0.34, 95% CI 0.30-0.39), from 11.4% (n=1539) to 5.3% (n=637). Predictors of inappropriate forceps polypectomy included: inadequate bowel prep (OR 1.25, 95% CI 1.06 – 1.47), polyps in the right colon (vs. left: OR 1.29, 95% CI 1.09 – 1.51), and number of polyps removed (OR 0.96, 95% CI 0.94 – 0.97). Inappropriate forceps polypectomy also varied by gastroenterologist (median odds ratio 3.43). In a post-hoc analysis, the proportion of polyps >2mm removed with forceps decreased from 50.0% before the intervention to 43.0% after it (OR 0.62, 95% CI 0.58-0.68). CONCLUSIONS Inappropriate forceps polypectomy is common but modifiable. The proportion of non-diminutive polyps removed with forceps polypectomy should be considered as a quality measure.

Objective: During its first year, the AWARE study assessed disease activity, patient quality of life (QOL), and treatment patterns in chronic urticaria (CU) refractory to H1-antihistamines (H1-AH) in clinical practice. Methods: We performed an observational, prospective (24 months), international, multicenter study. The inclusion criteria were age ≥18 years and H1-AH–refractory CU (>2 months). At each visit, patients completed questionnaires to assess disease burden (Urticaria Control Test [UCT]), disease activity (7 day-Urticaria Activity Score [UAS7]), and QOL (Dermatology Life Quality index [DLQI], Chronic Urticaria Quality of Life Questionnaire [CU-Q2oL], and Angioedema Quality of Life Questionnaire [AE-QoL]). We present data for Spain. Results: The study population comprised 270 evaluable patients (73.3% female, mean [SD] age, 48.9 [14.7] years). At baseline, 89.3% were prescribed a CU treatment. After 1 year, first- and second-line treatments became less frequent and third-line treatments became more frequent. At baseline, 47.0% of patients experienced angioedema; at 1 year, this percentage had fallen to 11.8%. The mean (SD) AE-QoL score decreased from 45.2 (28.7) to 24.0 (25.8). The mean (SD) UCT score decreased from 7.0 (4.5) to 12.1 (4.1). According to UAS7, 38.2% of patients reported absence of wheals and itch in the previous 7 days at 1 year compared with 8.3% at baseline. The mean (SD) DLQI score decreased from 8.0 (7.4) to 2.8 (4.6). At the 1-year visit, the percentage of patients reporting a high or very high impact on QOL fell from 29.9% to 9.6%. Conclusions: H1-AH–refractory CU in Spain is characterized by absence of symptoms and a considerable impact on QOL. Continuous follow-up of CU patients and third-line therapies reduce disease burden and improve patients’ QOL.

Background and objective Ultrasound has been included in the training of residents in rheumatology in recent years, as a result of its increased use in daily clinical practice. Our objective is to evaluate the perceived quality of ultrasound training of residents in rheumatology services in Spain. Material and methods Online survey aimed at rheumatologists who began their training in rheumatology between 2009 and 2019. Results One hundred thirty-nine rheumatologists participated in the survey, of which 97.1% had at least one ultrasound machine in their training centre. Up to 51.1% performed a rotation in ultrasound and 56% had an ultrasound consultation. Access to SER courses was high (87.8%) while access to EULAR courses was limited (17.3%) and up to 69.1% of residents did not complete the competency accreditation. Training in evaluation of inflammatory joint activity, entheses and microcrystalline diseases received the highest scores. Evaluation of ultrasound training during the residency was good in 36% of cases, fair in 28.1%, poor in 18% and excellent in 12.9%. Of those surveyed, 88% consider their clinical practice as a rheumatologist to have improved. Conclusions Most residents have performed ultrasound rotations. Participation in SER ultrasound courses is high and moderate in EULAR courses, while only a minority completed the competency accreditation. The overall degree of satisfaction with training in ultrasound during residency is good and, in the opinion of residents, contributes to the improvement of their skills as rheumatologists.

Objective The MitraClip from Abbott is FDA approved intracardiac implantable device for transcatheter edge-to-edge repair (TEER). Despite a few previously published studies, there is limited safety data for its use in clinical practice, hence, we designed this study using data obtained from a safety nationwide database to demonstrate the safety profile of MitraClip. Methods The first two of the five authors independently queried all reported adverse events from the United State Food and Drug Administration [FDA] Manufacturer and User Facility Device Experience [MAUDE] registry from January 2014 to December 2020. The primary end point was trend in reported fatal events obtained from this database. The secondary end points included the causes of reported nonfatal reports from the MAUDE registry. The trend of reported fatal events was assessed using the Cochran Armitage trend test over the period of the study. Results During the study period, subjects included 3370 patients whose MitraClip-associated adverse events were reported and captured by MAUDE registry. Of these, 211 were fatal and 3159 nonfatal events. Fatal event reports resulted deaths and reported nonfatal events were from injuries and device system malfunction. This study demonstrated an initial upward trend from 2014 to 2015 then a subsequent statistically significant downward trend in reported fatal events from 2015 to 2020 (Cochran-Armitage test P = 0.039). The peak proportion of reported fatal events occurred in 2015, (n = 44; representing 1.25% of reported adverse events) and lowest proportion of reported fatal events took place in 2020 (n = 19; representing 0.56% of reported adverse events). The most reported nonfatal events were from malfunctioning of MitraClip system (n = 1170; representing 37% of reported nonfatal events), new unremarkable repolarization abnormalities on periprocedural EKG (n = 864; representing 27% of reported nonfatal events), leaflet rupture (n = 651; representing 21% of reported nonfatal events), and cardiogenic shock (n = 170; representing 5% of reported nonfatal events). Conclusions This analysis of the MAUDE Registry indicated, especially within the confines of this study's limitations and poor data quality of information, an apparent downward trend of reported fatal events over the study period. Even though conclusive attributions cannot be made regarding this important finding, perhaps, this points to early evidence of a potential institutional or operator learning curve with this device. However, in view of the inferior quality of the data accrued from the MAUDE Registry, more high-precision studies are needed to better understand these changes, as the utility of MitraClip, becomes more established in clinical practice.

Neuroprognostication following diffuse axonal injury (DAI) has historically relied on neuroimaging techniques with lower spatial resolution and contrast than techniques currently available in clinical practice. Since the initial studies of DAI classification and prognosis in the 1980s and 1990s, advances in neuroimaging have improved detection of brainstem microbleeds, a hallmark feature of Grade 3 DAI that has traditionally been associated with poor neurologic outcome. Here, we report clinical and radiologic data from two patients with severe traumatic brain injury and grade 3 DAI who recovered functional independence and returned to work within 4 months of injury. Importantly, both patients were scanned using 3 Tesla MRI protocols that included susceptibility-weighted imaging (SWI), a technique that provides enhanced sensitivity for detecting brainstem microbleeds. These observations highlight the importance of developing approaches to DAI classification and prognosis that better align with contemporary neuroimaging capabilities.

Responsive assessment of disease activity in patients who have rheumatoid arthritis (RA) is necessary to evaluate therapeutic efficacy and guide treatment. We compared the utility of the multibiomarker disease activity (MBDA) score in the assessment of RA disease activity with that of the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) score and the Clinical Disease Activity Index (CDAI) in a multicenter, randomized, placebo-controlled trial of repository corticotropin injection (RCI) in patients with persistently active RA.Patients received 80 units of RCI twice weekly during a 12-week open-label period; those who experienced low disease activity at week 12 were randomly assigned to receive either 80 units of RCI or placebo twice weekly during a 12-week double-blind period. Changes in disease activity (measured by DAS28-ESR, CDAI, and MBDA scores) and correlations between MBDA scores and both DAS28-ESR and CDAI scores were assessed.Changes from baseline in DAS28-ESR and CDAI scores suggested that RCI therapy led to clinically meaningful improvements in disease activity, but improvements from baseline in MBDA scores were below the minimally important difference threshold. For the DAS28-ESR and CDAI, correlations with total MBDA and individual component scores were generally low (r ≤ 0.3) and occasionally moderate (r 0.3 but r 0.5).The results of the present study suggest overall MBDA scores are not sufficiently responsive for assessing RA disease activity after RCI therapy. These findings are consistent with those seen with other RA drugs and, although they are from a clinical trial, suggest the MBDA should not be a preferred disease activity measure in clinical practice.

Purpose To determine the validity of Intrapartum ultrasound (IPUS), and particularly the angle of progression (AOP), in predicting delivery mode when measured in real-life clinical practice among women with protracted second stages of labor. Methods Using electronic medical records, nulliparous women with a second stage of labor of ≥ 3hours ("prolonged") and a documented AOP measurement during the second stage were identified. The ability of a single AOP measurement in "prolonged" second stage to predict a vaginal delivery (VD) was assessed. Fetal head descend, measured by AOP change/hour (calculated from serial measurements) was compared between women who delivered vaginally and those who had a cesarean delivery (CD) for arrest of descent. Results Of the 191 women who met the inclusion criteria, 62 (32.5%) delivered spontaneously, 96 (50.2%) had a vacuum extraction (VE) and 33 (17.3%) had a CD. The mean AOP was wider among women who had VD (spontaneous or VE) compared to those who had CD (153º±19 vs. 133º±17, p

Background Paraplegia remains one of the most devastating complications of descending and thoracoabdominal aortic repair. The aim of this review is to outline the current state of art in the rapidly developing field of spinal cord injury research. Methods A review of PubMed and Web of Science databases was performed using the following terms and their combinations: spinal cord, injury, ischemia, ischemia-reperfusion, ischemic spinal cord injury, paraplegia, paraparesis. Articles published before July 2019 were screened and included if considered relevant. Results The review focuses on the topic of spinal cord injury and the developments concerning methods of monitoring, diagnosing, and preventing spinal cord injury. Conclusions Translation of novel technologies from bench to bedside and into everyday clinical practice is challenging; however, each of the developing areas holds great promise in spinal cord injury prevention.

Objective To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins. Methods We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication – in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation. Results In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively. Conclusion Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures. Practice implications Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.

Background The purpose of this study was to learn about the clinical practice of specialists who care for patients with giant cell arteritis, to verify whether they follow the diagnosis and treatment recommendations for this disease, and to identify areas for improvement. Methods A cross-sectional survey on clinical practice in 2019. The survey was completed by 167 physicians (64% rheumatologists, 27% internal medicine specialists, and 9% other specialists) who attended a course on updating giant cell arteritis treatment. We compared the clinical practice collected in the study with the latest recommendations approved by the European League Against Rheumatism (EULAR). Results The physicians surveyed cared for a median of 10 patients (interquartile range 6–30) with giant cell arteritis during their practice. As a diagnostic method, respondents used temporal artery biopsy (84%), temporal artery ultrasound (61%) or other imaging techniques (37%). As first-line therapy, respondents used high-dose glucocorticoids (at least 40 mg of prednisone, or equivalent, per day) (84%), glucocorticoids with methotrexate (7%) and glucocorticoids with tocilizumab (5%). The most frequent drugs used for relapse were methotrexate (37%) and tocilizumab (58%). Conclusion Our results indicate that the medical specialists surveyed follow the recent EULAR recommendations for giant cell arteritis diagnosis and therapy.

This review sets forth an approach to performing and interpreting shoulder ultrasound in patients with prior rotator cuff repair and presents a comprehensive review of normal expected findings, postsurgical complications and common artifacts encountered in clinical practice.

Acute kidney injury (AKI) is a common syndrome that has a significant impact on prognosis in various clinical settings. To evaluate whether new evidence supports changing the current definition/classification/staging systems for AKI suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline, the Taiwan AKI-TASK Force, composed of 64 experts in various disciplines, systematically reviewed the literature and proposed recommendations about the current nomenclature and diagnostic criteria for AKI. The Taiwan Acute Kidney Injury (TW-AKI) Consensus 2020 was established following the principles of evidence-based medicine to investigate topics covered in AKI guidelines. The Taiwan AKI-TASK Force determined that patients with AKI have a higher risk of developing chronic kidney disease, end-stage renal disease, and death. After a comprehensive review, the TASK Force recommended using novel biomarkers, imaging examinations, renal biopsy, and body fluid assessment in the diagnosis of AKI. Clinical issues with regards to the definitions of baseline serum creatinine (sCr) level and renal recovery, as well as the use of biomarkers to predict renal recovery are also discussed in this consensus. Although the present classification systems using sCr and urine output for the diagnosis of AKI are not perfect, there is not enough evidence to change the current criteria in clinical practice. Future research should investigate and clarify the roles of the aforementioned tools in clinical practice for AKI.

HIV reverse transcriptase (RT) inhibitors are the important components of highly active antiretroviral therapies (HAARTs) for anti-HIV treatment and pre-exposure prophylaxis in clinical practice. Many RT inhibitors and their combination regimens have been approved in the past ten years, but a review on their drug discovery, pharmacology, and clinical efficacy is lacking. Here, we provide a comprehensive review of RT inhibitors (tenofovir alafenamide, rilpivirine, doravirine, dapivirine, azvudine and elsulfavirine) approved in the past decade, regarding their drug discovery, pharmacology, and clinical efficacy in randomized controlled trials. Novel RT inhibitors such as islatravir, MK-8504, MK-8507, MK8583, IQP-0528, and MIV-150 will be also highlighted. Future development may focus on the new generation of novel antiretroviral inhibitors with higher bioavailability, longer elimination half-life, more favorable side-effect profiles, fewer drug-drug interactions, and higher activities against circulating drug-resistant strains. ispartof: Acta Pharm Sin B vol:12 issue:4 pages:1567-1590 ispartof: location:Netherlands status: published

Climate change is the most critical public health crisis of the 21st century. Physical and medical sequelae of climate and weather-related events are well documented and may be addressed in clinical practice. Mental health impacts of climate change are increasingly addressed in the literature but remain underrecognized by clinicians. This report focuses on mental health impacts of climate change through the theoretical framework of Maslow’s Hierarchy of Needs. It offers a broad overview of mental health impacts, particularly for vulnerable populations, and introduces screening, assessment, and treatment considerations for the nurse practitioner.

Most patients with psoriasis present with localized mild-to-moderate disease. In this case, the application of topical treatments in the first-line setting is recommended in most cases. Among different topical options, the fixed-dose combination of betamethasone dipropionate (BD) and vitamin D analogue (Cal) aerosol foam (Enstilar®, Leo Pharma) is approved as first-line topical therapy for the treatment of psoriasis in USA and the EU, due to its high efficacy and its favorable administration scheme. The PSO-LONG was the first trial to report on the long-term efficacy and safety of the Cal/DB foam treatment for the proactive management of psoriasis and now, the indications of Cal/BD foam included its use in the psoriasis maintenance treatment. However, the precise role of this treatment and the potential therapeutic schemes in the long-term management of psoriasis need further clarification. This Position Paper, authored by a group of Italian Expert Dermatologists, critically discusses the long-term management of psoriasis with Cal/BD foam in clinical practice. In particular, the biological rationale in the proactive treatment with Cal/BD foam and current evidence regarding this therapeutic approach are presented, along with its application also in patients with moderate-to-severe disease, difficult-to-treat lesions, or within combination regimens. In addition, strategies to improve adherence to long-term treatment of psoriasis are discussed,.

Background Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. However, it is unclear which scores have undergone external validation, and which score is the most accurate. Objective To identify risk scores for POPF, and assess the clinical validity of these scores. Methods Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models. Results Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so were included in the meta-analysis, namely the Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores. The overall predictive accuracies were found to be similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%. Conclusion Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.

Asthma is one of the most common causes of emergency department (ED) visits in children. Therapy delivered through a meter dose inhaler with spacer (MDI + S) is equally as effective as nebulization in mild and moderate asthma exacerbations but was not routinely prescribed in the ED at the largest tertiary center for pediatrics in the United Arab Emirates (UAE). Phase 1 of this cohort study involved a validated survey to evaluate physicians' knowledge, attitudes and perceptions towards MDI therapy. While 62% of physicians reported that MDI + S was equally effective as nebulizers and 82% believed that they had sufficient knowledge with regard to its use, only 28% prescribed it. Perceived barriers to change of practice included: Lack of clinical practice guidelines (CPG), poor knowledge amongst nurses and physicians, caregivers' reluctance and a difficult prescription process. Phase 2 consisted of administering the same survey after completing interventions to address the aforementioned barriers. Comparisons were made between the subgroups within phase 1 and statistically significant differences were noted with a p value .05. The number of physicians who prescribed MDI + S increased from 28% to 41% (p value = .046). Moreover, physicians who believed that convincing parents to use MDI + S therapy would be easy, increased from 35% to 66% (p value .0001). In conclusion, more physicians reported prescribing MDI + S in Phase 2 while concerns about barriers that exist to change in practice remained similar in both phases showing that consistent and prolonged advocacy is required to achieve long-term compliance.

Background and Purpose: Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. Methods: We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry—a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. Results: Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57–1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11–3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27–2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score Conclusions: Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.

Background and Purpose: The benefit of endovascular treatment (EVT) for posterior circulation stroke (PCS) remains uncertain, and little is known on treatment outcomes in clinical practice. This study evaluates outcomes of a large PCS cohort treated with EVT in clinical practice. Simultaneous to this observational study, several intervention centers participated in the BASICS trial (Basilar Artery International Cooperation Study), which tested the efficacy of EVT for basilar artery occlusion in a randomized setting. We additionally compared characteristics and outcomes of patients treated outside BASICS in trial centers to those from nontrial centers. Methods: We included patients with PCS from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry: a prospective, multicenter, observational study of patients who underwent EVT in the Netherlands between 2014 and 2018. Primary outcome was a score of 0 to 3 on the modified Rankin Scale at 90 days. Secondary outcomes included reperfusion status and symptomatic intracranial hemorrhage. For outcome comparison between patients treated in trial versus nontrial centers, we used ordinal logistic regression analysis. Results: We included 264 patients of whom 135 (51%) had received intravenous thrombolysis. The basilar artery was most often involved (77%). Favorable outcome (modified Rankin Scale score 0–3) was observed in 115/252 (46%) patients, and 109/252 (43%) patients died. Successful reperfusion was achieved in 178/238 (75%), and symptomatic intracranial hemorrhage occurred in 9/264 (3%). The 154 nontrial patients receiving EVT in BASICS trial centers had similar characteristics and outcomes as the 110 patients treated in nontrial centers (modified Rankin Scale adjusted cOR: 0.77 [95% CI, 0.5–1.2]). Conclusions: Our study shows that high rates of favorable clinical outcome and successful reperfusion can be achieved with EVT for PCS, despite high mortality. Characteristics and outcomes of patients treated in trial versus nontrial centers were similar indicating that our cohort is representative of clinical practice in the Netherlands. Randomized studies using modern treatment approaches are needed for further insight in the benefit of EVT for PCS.

This study is the first to distinguish two possible predictive directions between trauma exposure and executive functioning in children in a community sample. The sample consists of 1006 children from two time points with a seven years’ time interval of a longitudinal Dutch birth cohort study, the ABCD-study (Van Eijsden et al., 2011). We analyzed the longitudinal associations between trauma exposure and executive functioning using structural equation modeling. The results demonstrated that (after controlling for prenatal substance exposure and mothers’ educational level) trauma exposure before age 5 is predictive of poorer executive functioning at age 12 and trauma exposure between age 6 and 12. However, the association between executive functioning at age 5 and trauma exposure between age 6 and 12 was not statistically significant. Our results indicate that early life trauma exposure has a long term impact on later executive functioning and not the other way around. On top of that, trauma exposure seems to accumulate across childhood when children are exposed to a traumatic event before the age of 5. When looking at the potential moderating role of parenting behavior we found no evidence for such a moderating effect of parenting behavior. Our findings showed that children exposed to trauma early in life may experience problems in executive functioning later in life and they seem at higher risk for cumulative trauma exposure. Clinical practice should take this into account in both the way they provide (early) mental health care and in prevention and recognition of early trauma exposure.

Optical imaging modalities are emerging as digital microscopy tools for tissue examination. The investigation of these techniques for potential applications in anatomic pathology practice has focused primarily on surgical pathology and has not included cytopathological specimens. We evaluated the feasibility of using digital confocal microscopy (CM) to examine cytopathological specimens. Smears and cell suspensions collected in RPMI solution were prepared from tissue scrapes obtained from surgical resections of breast, lung, liver, and kidney. Air-dried smears and cell pellets obtained from centrifugation of the cell suspensions were stained with 0.6 mM acridine orange and imaged with a CM platform. After completion of imaging, the smears were stained with Diff-Quik (DQ), and cell pellets were routinely processed, embedded in paraffin wax, cut, and stained with hematoxylin and eosin (HE). We evaluated the mean time to acquire digital CM images; quality of images based on the extent of tissue recognition (0%, grade 0; 1-19%, grade 1; 20-50%, grade 2;50%, grade 3); comparison of images with DQ- and HE-stained specimens; and ability to make specific diagnoses. We imaged 91 smears and 52 cell pellets and acquired digital CM images within 2-3 min, with 92% and 88% of images, respectively, from smears and cell pellets showing grade 3 quality. On the basis of CM images, 8 smears (9%) and 7 cell pellets (14%) were categorized as benign, and 83 (91%) and 45 (88%), respectively, as malignant. Specific diagnoses were made by using digital CM images of smears and cell pellets that matched accurately with corresponding DQ- and HE-stained preparations. The results of our first feasibility study clearly indicated the utility of CM as a next-generation digital microscopy tool for evaluating cytology specimens. Prospective clinical studies are warranted for validating our findings for potential incorporation into cytopathological clinical practice.

Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.

Yoga therapy is an emerging integrative health approach that applies the practices and teachings of yoga for individuals with clinical concerns. It is generally offered as individual sessions between a yoga therapist and client or in a small group setting with several clients who share a clinical concern. Here we describe a third model for consideration- the yoga therapy dyad. A dyad includes two clients working simultaneously with a single yoga therapist and differs from both individual and small group sessions in the potential benefits and challenges. The yoga therapy dyad model that is detailed here was implemented as part of a feasibility trial along with group acupuncture therapy for chronic pain in an underserved population. Underserved populations are at risk for pain and reduced access to care. This pilot may inform future research, policy, education, and clinical practice.

In the last 2 decades, an increasing understanding of pathophysiological mechanisms in chronic rhinosinusitis (CRS) opened an avenue from phenotyping to endotyping, from eosinophilic inflammation to type 2 immunity, and from the ventilation and drainage paradigm to the mucosal concept for therapeutic considerations. With the advent of type 2 endotyping and targeted biomarkers, precise endotype-driven therapeutic options are possible including biologics and adapted surgical approaches. We here aim to focus on the complexity and heterogeneity of the features of CRS endotypes, especially for those with nasal polyps, including its history, latest developments, clinical associations, and endotype-driven solutions. In order to better manage uncontrolled severe CRS in clinical practice, medical decisions based on a profound understanding of the pathology and immunology of this heterogeneous disease, aiding a precision-medicine based approach for patient's treatment, are pivotal.

Noninferiority trials are increasingly used in urology. Understanding the methodology and assessment of such trials can be challenging for clinicians. We provide an approach to interpreting the results, validity, and applicability of noninferiority studies in clinical practice.

Benign main bronchial stenosis may cause a potentially life-threatening condition. Airway silicone stenting is an important option of bronchoscopic treatments for patients with main bronchial stenosis. However, stent migration is one of the most frequent complications, which require repeated bronchoscopic interventions. To resolve this issue, we therefore in the report described a novel designed V-shaped silicone stent for the treatment of unilateral main bronchial stenosis. This method may be widely applied to clinical practice to prevent stent migration.

Considerable progress has been made in the field of molecular biology in recent years, enabling the study of sensitization to the individual components of an allergenic source, a practice that has been termed molecular allergy diagnosis (MD) or component-resolved diagnosis (CRD). The present review provides the clinician with a practical approach to the use of MD by answering questions frequently asked by physicians on how MD can help improve the diagnosis of allergy in daily clinical practice. The article is divided into 3 sections. First, we provide a brief review of the importance for the clinician of knowing the main allergens in the different allergenic sources, their structure, and their in vitro cross-reactivity before approaching MD (section A). Second, we review the usefulness of MD in clinical practice (section B) and answer frequently asked questions on the subject. Finally, section C addresses the interpretation of MD and its integration with other tools available for the diagnosis of allergy.

Wheelchair propulsion interventions typically teach manual wheelchair users to perform wheelchair propulsion biomechanics as recommended by the Clinical Practice Guidelines (CPG). Outcome measures for these interventions are primarily laboratory based. Discrepancies remain between manual wheelchair propulsion (MWP) in laboratory-based examinations and propulsion in the real-world. Current developments in machine learning (ML) allow for monitoring of MWP in the real world. In this study, we collected data from participants enrolled in two wheelchair propulsion interventions, then built an ML algorithm to distinguish CPG recommended MWP patterns from non-CPG-recommended patterns. Eight primary manual wheelchair users did not initially follow CPG recommendations but learned and performed CPG propulsion after the interventions. Participants each wore two inertial measurement units as they propelled their wheelchairs on a roller system, indoors overground, and outdoors. ML models were trained to classify propulsion patterns as following the CPG or not following the CPG. Video recordings were used for reference. For indoor detection, we found that a subject-independent model was able to achieve 85% accuracy. For outdoor detection, we found that the subject-independent model achieved 75.4% accuracy. These results provide further evidence that CPG and non-CPG-recommended MWP patterns can be predicted with wearable sensors using an ML algorithm.

This review article serves to assess the consistency of recommendations from guidelines on biologic agents for psoriasis, based on the quality evaluation of psoriasis Clinical Practice Guidelines (CPGs).We conducted a systematic literature search to identify CPGs that provide recommendations on diagnosis and treatment for psoriasis. Four reviewers performed a quality assessment of the included CPGs with the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument.A total of 51 sets of CPGs from 22 medical societies or separate working groups fulfilled the inclusion criteria. The overall quality of the eligible sets of guidelines was moderate to high, with an overall average score of 55%. The highest domain scores were Score and Purpose (70%) and Clarity of Presentation (68%). A total of 95 biologic agent recommendations were extracted from the 18 recommended CPGs. Three biologic agents (Etanercept, Adalimumab, Ustekinumab) were recommended for pediatric patients. Three biologic agents (Adalimumab, Ustekinumab, Secukinumab) were recommended as first-line biologic agents for adults with psoriasis.The overall methodological quality of CPGs for psoriasis is medium to high. More attention should be paid to applicability in guideline development. The recommendations and the basis for them among various sets guidelines were almost consistent.

Loss of cardiac muscle after cardiac injury is replaced by cardiac fibrosis, due to very limited regenerative capacity of the heart. Although initially beneficial, persistent cardiac fibrosis leads to pump failure and conduction abnormalities, common modes of death following cardiac injury. Thus, directly reprogramming cardiac fibroblasts into induced cardiomyocyte-like cells (iCMs) by forced expression of cardiogenic factors (referred to as cardiac reprogramming) is particularly attractive in that it targets cardiac fibroblasts, a major source of cardiac fibrosis, to induce new cardiac muscle. Over the last decade, remarkable progresses have been made on cardiac reprogramming, particularly focusing on how to enhance conversion of fibroblasts to iCMs in vitro. However, it still remains elusive whether this new regenerative approach can be translated into clinical practice. This review discusses progresses and challenges of cardiac reprogramming in the translational context.

Overdrainage of cerebrospinal fluid is one of the most notorious complications after ventriculoperitoneal shunt implantation. Siphon effect plays a major role in the development of overdrainage. Various overdrainage-preventing devices have been invented to counteract the siphon effect. Though some of the devices are designed to reduce the flow instead of providing antisiphoning effect, they are generally called antisiphon devices (ASDs). The basics of siphoning, the mechanisms and physical properties of currently available devices are described in this article. The clinical efficacy, shunt survival, and considerations on patient factors are also discussed. There are three kinds of ASD design, diaphragm, gravitational, and flow reducing devices. Flow reducing ASD is always open and the flow it controls is relatively stable. On the other hand, it may not provide sufficient flow in nocturnal intracranial pressure elevations. Diaphragm and gravitational devices are sensitive to the position of the patients. Diaphragm device is sensitive to the external pressure and the relative position of the device to the mastoid process. The gravitational device is sensitive to the angle between the axis of the device and the head. Many studies showed encouraging results with gravitational devices. Studies regarding diaphragm devices either showed better or similar outcomes comparing to differential pressure valves. Clinical studies regarding flow-reducing devices and head-to-head comparison between different mechanisms are warranted. This review aims to provide a useful reference for clinical practice of hydrocephalus.

Background The current classification for alopecia areata (AA) does not provide a consistent assessment of disease severity. Objective To develop an AA severity scale based on expert experience. Methods A modified Delphi process was utilized. An advisory group of 22 AA clinical experts from the United States was formed to develop this AA scale. Representatives from the pharmaceutical industry provided feedback during its development. Results Survey responses were used to draft severity criteria, aspiring to develop a simple scale that may be easily applied in clinical practice. A consensus vote was held to determine the final AA severity statement, with all AA experts agreeing to adopt the proposed scale. Limitations The scale is a static assessment intended to be used in clinical practice and not clinical trials. Conclusion The final AA disease severity scale, anchored in the extent of hair loss, captures key features commonly used by AA experts in clinical practice. This scale will better aid clinicians in appropriately assessing severity in patients with this common disease.

Airway management, including tracheal intubation and tracheostomy, is the most commonly performed procedure in critically ill patients. The EAMS held a webinar in June 2021 focused on this subject. Vincenzo Russotto from Monza, Italy and Sheila Myatra from Mumbai, India presented the results of the "INternational observational study To Understand the impact and BEst practices of airway management in critically ill patients”, the INTUBE study. The attendees of the EAMS webinar asked questions related to the study and the complications in critically ill patients. The present article summarises the discussion together with strategies to help clinicians prevent and treat these complications.

The growing use of imaging examinations has led to increased detection of spontaneous coronary artery dissection (SCAD) as a non-atherosclerotic cause of acute coronary syndrome (ACS). Since a greater awareness of pathophysiologic mechanisms has relevant implications in clinical practice, we aim to provide an update to current knowledge of SCAD pathophysiology. We discuss the most common conditions associated with SCAD, including predisposing factors and triggers, and focus on potential mechanisms leading to SCAD development. Furthermore, we report the main genetic research findings that have shed further light on SCAD pathophysiology. Finally, we summarize practical considerations in SCAD management based on pathophysiologic insights.

Here we review the paradigm-change from one-size-fits-all psychiatry to more personalized-psychiatry, where we distinguish between 'precision psychiatry' and 'stratified psychiatry'. Using examples in Depression and ADHD we argue that stratified psychiatry, using biomarkers to facilitate patients to best 'on-label' treatments, is a more realistic future for implementing biomarkers in clinical practice.

The artificial intelligence (AI) revolution is well underway, including in the medical field, and has dramatically transformed our lives. An understanding of the basics of AI applications, their development, and challenges to their clinical implementation is important for clinicians to fully appreciate the possibilities of AI. Such a foundation would ensure that clinicians have a good grasp and realistic expectations for AI in medicine and prevent discrepancies between the promised and real-world impact. When quantifying the track record for AI applications in cardiology, we found that a substantial number of AI systems are never deployed in clinical practice, although there certainly are many success stories. Successful implementations shared the following: they came from clinical areas where large amount of training data was available; were deployable into a single diagnostic modality; prediction models generally had high performance in external validation; and most were developed as part of collaborations with medical device manufacturers who had substantial experience with implementation of new clinical technology. When looking into the current processes used for developing AI-based systems, we suggest that expanding the analytic framework to address potential deployment and implementation issues at project outset will improve the rate of successful implementation, and will be a necessary next step for AI to achieve its full potential in cardiovascular medicine.

Cardiac implantable electronic devices establish proper therapy for the prevention of sudden cardiac death, significantly reducing the morbidity and mortality of patients with arrhythmias and heart failure. It is well-known that the number of electrodes increases the risk of complications. To preserve the benefit of atrial sensing without the need to implant an additional lead, a single-lead ICD system with a floating atrial dipole (DX ICD lead) has been developed. Besides all of the potential benefits, the necessity of a reliable and stable atrial sensing via the floating dipole could be the main concern against the use of this lead type. In the current generation of DX devices, the specially filtered atrial signal seems to be high enough and stable over time, which is crucial in the early detection of atrial arrhythmias, discrimination between different forms of tachycardias in order to prevent inappropriate ICD therapy, and achieving an optimal atrioventricular and interventricular synchrony in patients with a two-lead CRT-DX system. The present review summarizes the benefits and potential drawbacks of the DX ICD systems based on the available literature, furthermore, proposes an evidence-based algorithm of ICD type selection.