Treatment of Isolated Below the Knee Deep Vein Thrombosis

The natural history of isolated distal deep-vein thrombosis (IDDVT) is still uncertain, as well as the real clinical risks associated with the disease and the need for its diagnosis and treatment. While more and more IDDVTs are diagnosed in everyday clinical practice, their appropriate therapeutic management is, unfortunately, far from straightforward, and different recommendations on how patients with diagnosed IDDVT should be treated are present between expert professionals and even among international guidelines. The present article aims at briefly reviewing the issue of IDDVT therapy in general, particularly focusing on the different approaches to the treatment of the disease that have been suggested by recent guidelines, those that are currently adopted in clinical practice, and necessary future directions.     

Understanding health care organization needs and context. Beyond performance gaps

Significant efforts have been invested in improving our understanding of how to accelerate and magnify the impact of research on clinical practice. While approaches to fostering translation of research into practice are numerous, none appears to be superior and the evidence for their effectiveness is mixed. Lessons learned from formative evaluation have given us a greater appreciation of the contribution of context to successful implementation of quality improvement interventions. While formative evaluation is a powerful tool for addressing context effects during implementation, lessons learned from the social sciences (including management and operations research, sociology, and public health) show us that there are also powerful preimplementation tools available to us. This paper discusses how we might integrate these tools into implementation research. We provide a theoretical framework for our need to understand organizational contexts and how organizational characteristics can alert us to situations where preimplementation tools will prove most valuable.     

Understanding Health Care Organization Needs and Context

Significant efforts have been invested in improving our understanding of how to accelerate and magnify the impact of research on clinical practice. While approaches to fostering translation of research into practice are numerous, none appears to be superior and the evidence for their effectiveness is mixed. Lessons learned from formative evaluation have given us a greater appreciation of the contribution of context to successful implementation of quality improvement interventions. While formative evaluation is a powerful tool for addressing context effects during implementation, lessons learned from the social sciences (including management and operations research, sociology, and public health) show us that there are also powerful preimplementation tools available to us. This paper discusses how we might integrate these tools into implementation research. We provide a theoretical framework for our need to understand organizational contexts and how organizational characteristics can alert us to situations where preimplementation tools will prove most valuable.     

Depression and anxiety in heart failure

BACKGROUND: Although common among patients with heart failure, depression and anxiety have been relatively neglected by researchers and practitioners. Both depression and anxiety have been implicated in contributing independently to the poor outcomes seen in patients with heart failure. Emphasis in the literature is on physical symptom recognition and management, in contrast to the patient's perspective of the effects of heart failure on his or her daily life. METHODS AND RESULTS: This review summarizes and integrates research findings on anxiety and depression and translates these findings to clinical practice. Depression and anxiety are prevalent among patients with heart failure and require assessment and intervention. Short-term nonpharmacologic approaches, in conjunction with drug therapy, hold promise for successful management of patients who are depressed or anxious. CONCLUSION: Carefully designed clinical trials that are tailored to individual needs, yet are embedded within a systemic framework, are needed to inform clinicians regarding optimal practices for the treatment of patients with heart failure who suffer from depression or anxiety.     

Understanding health care organization needs and context

Significant efforts have been invested in improving our understanding of how to accelerate and magnify the impact of research on clinical practice. While approaches to fostering translation of research into practice are numerous, none appears to be superior and the evidence for their effectiveness is mixed. Lessons learned from formative evaluation have given us a greater appreciation of the contribution of context to successful implementation of quality improvement interventions. While formative evaluation is a powerful tool for addressing context effects during implementation, lessons learned from the social sciences (including management and operations research, sociology, and public health) show us that there are also powerful preimplementation tools available to us. This paper discusses how we might integrate these tools into implementation research. We provide a theoretical framework for our need to understand organizational contexts and how organizational characteristics can alert us to situations where preimplementation tools will prove most valuable.     

Cardiomyopathies:Evolution of pathogenesis concepts and potential for new therapies

Cardiomyopathies are defined as diseases of the myocardium with associated structural and functional abnormalities. Knowledge of these pathologies for a long period was not clear in clinical practice due to uncertainties regarding definition,classification and clinical diagnosis. In recent decades,major advances have been made in the understanding of the molecular and genetic issues,pathophysiology,and clinical and radiological assessment of the diseases. Progress has been made also in management of several types of cardiomyopathy. Advances in the understanding of these diseases show that cardiomyopathies represent complex entities. Here,special attention is given to evolution of classification of cardiomyopathies,with the aim of assisting clinicians to look beyond schematic diagnostic labels in order to achieve more specific diagnosis. Knowledge of the genotype of cardiomyopathies has changed the pathophysiological understanding of their etiology and clinical course,and has become more important in clinical practice for diagnosis and prevention of cardiomyopathies. New approaches for clinical and prognostic assessment are provided based on contemporary molecular mechanisms of contribution in the pathogenesis of cardiomyopathies. The genotype-phe-notype complex approach for assessment improves the clinical evaluation and management strategies of these pathologies. The review covers also the important role of imaging methods,particularly echocardiography,and cardiac magnetic resonance imaging in the evaluation of different types of cardiomyopathies. In summary,this review provides complex presentation of current state of cardiomyopathies from genetics to management aspects for cardiovascular specialists.     

From knowledge to practice in chronic cardiovascular disease: a long and winding road

Although clinical practices evolve over time, the translation of specific research evidence into clinical practice is unpredictable, inconsistent, and complex. In this paper, we use examples from chronic cardiovascular conditions to: 1). highlight two types of care gaps; 2). describe the most common potential barriers to the application of evidence into clinical care; and 3). outline which of the strategies for translating evidence into clinical care have been shown to be ineffective, which strategies have been shown to be effective and to describe some untested approaches that hold promise.     

Management of post-prostatectomy erectile dysfunction

The management of post-prostatectomy erectile function has been debated since the nerve sparing radical prostatectomy was first introduced. A number of penile rehabilitation protocols have been proposed with varying degrees of success and patient satisfaction. My management of post-prostatectomy erectile dysfunction has evolved based on an honest and critical appraisal of the literature and my own experience and research. A review of major studies published on the topic of post-prostatectomy penile rehabilitation is included here, in addition to a critical evaluation of my own clinical practice. After evaluating the efficacy of these various approaches, it is clear to me that a nerve sparing procedure is only one of many factors involved in recovering erectile function. Moreover, in addition to assessing a patient's goals and their motivation for erectile function after prostatectomy, setting appropriate patient expectations is paramount to avoiding patient frustration. A frank evaluation and discussion with a patient and their partner is paramount to managing these expectations. A "one size fits all" approach is not appropriate. Herein, I discuss the evolution of my approach to managing post-prostatectomy erectile dysfunction.     

Advances create opportunities: implementing the major tenets of the new unstable angina guidelines in the emergency department

Of all the clinical syndromes with which emergency physicians must deal, chest pain of coronary cause has benefited from the most striking recent advances both in diagnostic approach (cognitive and technologic) and in therapeutic options. Chest pain evaluation and management have become important foci of research in emergency medicine, and entire units are dedicated to its clinical prosecution in emergency departments and elsewhere in the hospital. New diagnostic tools are proposed and studied on a regular basis. Antiplatelet, antithrombin, and fibrinolytic agents unknown in clinical practice as recently as 5 years ago have secured places in the emergency physician's armamentarium for treating acute coronary syndrome. Many of these diagnostic and therapeutic tools have been developed in the coronary care unit and in the cardiac catheterization laboratory. Although intuitively they may also be useful outside of those settings, they have unreliably been brought to the ED for implementation and resultant appropriate prompt and early care of the coronary patient who does not meet fibrinolytic criteria. As emergency physicians seek to bring accurate chest pain risk stratification into their practice and begin to use new therapeutic agents to minimize myocardial damage before turning the patient's care over to other specialists, it is essential that they are familiar with the data supporting these approaches. In this commentary, we seek to place the American College of Cardiology/American Heart Association unstable angina guidelines into the clinical context of the ED.     

Assessing liver fibrosis

Prognosis and management of chronic liver diseases greatly depend on the amount and progression of liver fibrosis. Although liver biopsy is still considered as the gold standard to evaluate fibrosis in the liver, it is an invasive procedure, with rare but potentially life-threatening complications, and is prone to sampling errors. These limitations have stimulated the search for new noninvasive approaches. A number of methods, including serum indices and the measurement of liver stiffness using transient elastography, have been proposed for the noninvasive assessment of hepatic fibrosis, mainly in patients with chronic hepatitis C. It can be anticipated that these noninvasive methods will become an important tool in clinical practice in the near future. This review is aimed at discussing the advantages and limits of these methods and the perspectives for their rationale for use in clinical practice.     

Research within the field of blood and marrow transplantation nursing: how can it contribute to higher quality of care?

Nursing Science and research within BMT started in the early 80s and has been shown to be a useful contribution to obtain and maintain high standards of care. Trial and error are no longer accepted. The first studies were conducted together with the clinical developments and focused specifically on symptom control and management of the treatment. The term "evidence-based nursing" (EBN) is nowadays often used to describe the influence of research on practice. And yet we find that in general, care given by nurses is not yet based according to the guidelines established by research. There are several reasons why care is not (yet) based on results from research, like language barrier, diversity in health care and nursing educational systems, financial restrains and different roles and perceptions of nurses around the globe. Many nursing or multidisciplinary research studies have been conducted worldwide on areas such as the prevention or care for patients with mucositis, fatigue or pain, care for the central venous access devices, outpatient management of care, care for the donor and aspects of quality of life. Results have implications on practice and start to show their impact on quality of care. Many questions remain unanswered. Results from basic science (e.g. the discussion around fetal liver and embryonic derived stemcells and their use in treatment other than hematologic malignancies) and developments in medical treatments (e.g. introduction of tyrosin-kinase inhibitor, biotherapy and genetherapy) have an impact on nursing and should therefore be investigated closely to develop clinical pathways. It is obvious that much more time, finances, collaboration and support is needed to conduct powerful studies that can influence care for the BMT patient. This presentation will focus on developments through nursing research within the field of BMT and discuss gaps that will need to be filled in the near future.     

Myocardial protection at a crossroads: the need for translation into clinical therapy

Over the past 30 years, hundreds of experimental interventions (both pharmacologic and nonpharmacologic) have been reported to protect the ischemic myocardium in experimental animals; however, with the exception of early reperfusion, none has been translated into clinical practice. The National Heart, Lung, and Blood Institute convened a working group to discuss the reasons for the failure to translate potential therapies for protecting the heart from ischemia and reperfusion and to recommend new approaches to accomplish this goal. The Working Group concluded that cardioprotection in the setting of acute myocardial infarction, cardiac surgery, and cardiac arrest is at a crossroads. Present basic research approaches to identify cardioprotective therapies are inefficient and counterproductive. For 3 decades, significant resources have been invested in single-center studies that have often yielded inconclusive results. A new paradigm is needed to obviate many of the difficulties associated with translation of basic science findings. The Working Group urged a new focus on translational research that emphasizes efficacy and clinically relevant outcomes, and recommended the establishment of a system for rigorous preclinical testing of promising cardioprotective agents with clinical trial-like approaches (ie, blinded, randomized, multicenter, and adequately powered studies using standardized methods). A national preclinical research consortium would enable rational translation of important basic science findings into clinical use. The Working Group recommended that the National Institutes of Health proactively intervene to remedy current problems that impede translation of cardioprotective therapies. Their specific recommendations include the establishment of a preclinical consortium and the performance of 2 clinical studies that are likely to demonstrate effectiveness (phase III clinical trials of adenosine in acute myocardial infarction and cardiac surgery).     

Is precision medicine for colorectal liver metastases still a utopia? New perspectives by modern biomarkers,radiomics, and artificial intelligence

The management of patients with liver metastases from colorectal cancer is still debated. Several therapeutic options and treatment strategies are available for an extremely heterogeneous clinical scenario. Adequate prediction of patients’ outcomes and of the effectiveness of chemotherapy and loco-regional treatments are crucial to reach a precision medicine approach. This has been an unmet need for a long time, but recent studies have opened new perspectives. New morphological biomarkers have been identified. The dynamic evaluation of the metastases across a time interval, with or without chemotherapy, provided a reliable assessment of the tumor biology. Genetics have been explored and, thanks to their strong association with prognosis, have the potential to drive treatment planning. The liver-tumor interface has been identified as one of the main determinants of tumor progression, and its components, in particular the immune infiltrate, are the focus of major research. Image mining and analyses provided new insights on tumor biology and are expected to have a relevant impact on clinical practice. Artificial intelligence is a further step forward. The present paper depicts the evolution of clinical decision-making for patients affected by colorectal liver metastases, facing modern biomarkers and innovative opportunities that will characterize the evolution of clinical research and practice in the next few years.     

Heart failure disease management: implementation and outcomes

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.     

Chronic insomnia

Insomnia is a prevalent complaint in clinical practice that can present independently or comorbidly with another medical or psychiatric disorder. In either case, it might need treatment of its own. Of the different therapeutic options available, benzodiazepine-receptor agonists (BzRAs) and cognitive-behavioural therapy (CBT) are supported by the best empirical evidence. BzRAs are readily available and effective in the short-term management of insomnia, but evidence of long-term efficacy is scarce and most hypnotic drugs are associated with potential adverse effects. CBT is an effective alternative for chronic insomnia. Although more time consuming than drug management, CBT produces sleep improvements that are sustained over time, and this therapy is accepted by patients. Although CBT is not readily available in most clinical settings, access and delivery can be made easier through use of innovative methods such as telephone consultations, group therapy, and self-help approaches. Combined CBT and drug treatment can optimise outcomes, although evidence to guide clinical practice on the best way to integrate these approaches is scarce.     

Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology

Takotsubo syndrome is an acute reversible heart failure syndrome that is increasingly recognized in modern cardiology practice. This Position Statement from the European Society of Cardiology Heart Failure Association provides a comprehensive review of the various clinical and pathophysiological facets of Takotsubo syndrome, including nomenclature, definition, and diagnosis, primary and secondary clinical subtypes, anatomical variants, triggers, epidemiology, pathophysiology, clinical presentation, complications, prognosis, clinical investigations, and treatment approaches. Novel structured approaches to diagnosis, risk stratification, and management are presented, with new algorithms to aid decision‐making by practising clinicians. These also cover more complex areas (e.g. uncertain diagnosis and delayed presentation) and the management of complex cases with ongoing symptoms after recovery, recurrent episodes, or spontaneous presentation. The unmet needs and future directions for research in this syndrome are also discussed.     

Implementation strategies of Systems Medicine in clinical research and home care for cardiovascular disease patients

Insights from the “-omics” science have recently emphasized the need to implement an overall strategy in medical research. Here, the development of Systems Medicine has been indicated as a potential tool for clinical translation of basic research discoveries. Systems Medicine also gives the opportunity of improving different steps in medical practice, from diagnosis to healthcare management, including clinical research. The development of Systems Medicine is still hampered however by several challenges, the main one being the development of computational tools adequate to record, analyze and share a large amount of disparate data. In addition, available informatics tools appear not yet fully suitable for the challenge because they are not standardized, not universally available, or with ethical/legal concerns. Cardiovascular diseases (CVD) are a very promising area for translating Systems Medicine into clinical practice. By developing clinically applied technologies, the collection and analysis of data may improve CV risk stratification and prediction. Standardized models for data recording and analysis can also greatly broaden data exchange, thus promoting a uniform management of CVD patients also useful for clinical research. This advance however requires a great organizational effort by both physicians and health institutions, as well as the overcoming of ethical problems. This narrative review aims at providing an update on the state-of-art knowledge in the area of Systems Medicine as applied to CVD, focusing on current critical issues, providing a road map for its practical implementation.     

The enteric microbiota in the pathogenesis and management of constipation

For centuries, fiber has been recommended on an empirical basis for the management of constipation; it has only been in recent decades that the mechanisms whereby fiber and related products may influence colonic function have begun to be elucidated. The interaction between fiber and the microbiota of the human colon appears to play a major role in generating the beneficial effects of fiber. The microbiota is also the target for the other therapeutic interventions discussed in this chapter: prebiotics and probiotics. While a scientific basis for a role for these approaches in the management of constipation continues to develop, evidence from high-quality clinical trials to support their use in daily practice continues to lag far behind. While benefits for fiber and, perhaps, for certain prebiotic and probiotic preparations in constipation appear to be extant there is a real need for large well-conducted clinical trials in this important area of human medicine.     

全科住院医师规范化培训的技能教学探索——以成人体重管理为例

目的目前国内的全科住培医师教育主要集中在疾病的诊断与治疗上，对慢性病管理教学较为缺乏，本文将以成人体重管理为例探讨住院医师规范化培训中的技能教学。 方法与结果借鉴国内外有关超重、肥胖诊疗指南、临床实践从三方面制定教学内容：（1）提高学员们对肥胖患者的识别能力；（2）树立正确的诊断意识；（3）应用"ABCDEF"体重管理策略；并结合住院医师规范化培训的门诊教学，以教师示范-学员实践-师生反馈的方式制定教学实践计划。 结论全科住院医师规范化培训将成为我国全科医生输出的最大体系，因此体重管理技能教学应是规范化培训内容的重要组成部分，尽管该教学方法的临床适应性仍需探索，但它定能促进全科教学技能的发展，为未来的"健康守门人"赋予更强大的岗位胜任力。