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Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.

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Introduction: Pseudoaneurysm of the ulnar artery (PUA) can arise secondary to several inciting etiologies and may lead to pain, arterial insufficiency, and ulnar nerve palsy. Given the relative infrequency of PUA diagnosis, there is no consensus regarding its proper diagnosis and management strategies. The purpose of this review is to summarize the existing data regarding PUA and develop an algorithm for management. Methods: A review was performed following PRISMA Extension for Scoping Reviews guidelines. Manuscripts were included if they 1) studied patients over the age of 18, 2) discussed specifics of the PUA and 3) detailed its management. Results: Thirty-one manuscripts were included, presenting data on 32 patients with a mean â€‹± â€‹standard deviation age of 46.9 â€‹± â€‹19.6 years. Ulnar artery injury mechanism included trauma (13/32, 40.6 â€‹%), iatrogenic (9/32, 28.1 â€‹%), and inherent connective tissue disease (4/32, 12.5 â€‹%), among others. Ultrasonography was the most common imaging modality (14/32, 43.7 â€‹%), and a majority (22/32, 68.8 â€‹%) of patients were managed surgically, typically via pseudoaneurysm resection â€‹± â€‹venous grafting for reconstruction. Non-operative interventions included ultrasound-guided compression therapy and thrombin injection. Conclusion: While PUA are infrequently diagnosed, inciting events such as accidental or iatrogenic trauma continue to be documented, and management guidelines are lacking. Duplex ultrasonography is recommended as the first line imaging study, with subsequent Allen Test to assess for ulnar artery vs. mixed dominance for hand perfusion. A pseudoaneurysm of 3 â€‹cm is proposed as a general threshold for considering intervention, with caveats for smaller lesions causing pain or neurologic symptoms. This review serves as a reference for physicians who encounter PUA.

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PURPOSE: Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany. METHODS: Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room. RESULTS: A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%. CONCLUSIONS: In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.

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Introduction: Wet contamination was a common problem of peritoneal dialysis (PD) system. We developed a management algorithm for wet contamination of PD system (wet contamination) on the basis of the related research literature and clinical practice experience. The purpose of this study was to observe clinical effect of the management algorithm on the prevention of peritonitis. Methods: Patients treated wet contamination in a single PD center between October 2017 and September 2022 were included. A management algorithm was established to treat wet contamination. It comprised identification of the contamination type, addressing contaminated or aging catheters, prophylactic antibiotics, and retraining. Demographic data and clinical data about wet contamination were collected and compared. Results: One hundred and forty-one cases of wet contamination were included in this study. The mean age was 51.7 ± 14.1 years, and 49.6% were female. The proportion of diabetic nephropathy was 9.9%. The median PD duration was 27.0 (1.7-79.7) months. Eighteen episodes (12.8%) of wet contamination-associated peritonitis developed after wet contamination. The main pathogenic bacteria of peritonitis were Gram-positive bacteria (33.3%) and Gram-negative bacteria (27.8%). The incidence of wet contamination-associated peritonitis in the compliance with the management algorithm group was significantly lower than that in the non-compliance with the management algorithm group (0.9 vs. 48.6%; p < 0.001). Non-compliance with management algorithm (OR = 185.861, p < 0.001) together with advance age (OR = 1.116, p < 0.001) and longer distance from home to hospital (OR = 1.007, p < 0.001) were independent risk factors for wet contamination-associated peritonitis. Conclusion: The management algorithm for wet contamination of PD system could reduce the risk of peritonitis.

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BACKGROUND: The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study. METHODS: This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022. RESULTS: In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary. CONCLUSIONS: The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care.

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Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

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Purpose: This study aims to develop an accessible stepwise management algorithm for pediatric presentations of occipital condyle fractures (OCFs) based on a systematic review of the published literature regarding diagnostic evaluation, treatment, and outcomes. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric OCFs. Data extraction of clinical presentation, management strategies, imaging, and treatment outcome was performed. Results: A total of 15 studies reporting on 38 patients aged 18 years and younger presenting with OCFs were identified. Loss of consciousness (LOC), depressed level of consciousness, neck pain, decreased neck range of motion (ROM), and cranial nerve injury were the most common presenting symptoms. Diagnostic imaging included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and functional radiographs to assess cervical stability. Treatment options varied and included soft collar, hard collar, and halo vest. All studies resulted in a complete healing of the OCF, with resolution of associated pain. Conclusion: The proposed treatment algorithm suggests a framework for the management of pediatric OCFs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a stepwise approach should be utilized in the management of isolated pediatric OCFs.

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Objective: To conduct a systematic literature review on urethral calculi in a contemporary cohort describing etiology, investigation, and management patterns. Methods: A systematic search of MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed. Articles, including case reports and case series on urethral calculi published between January 2000 and December 2019, were included. Full-text manuscripts were reviewed for clinical parameters including symptomatology, etiology, medical history, investigations, treatment, and outcomes. Data were collated and analyzed with univariate methods. Results: Seventy-four publications met inclusion criteria, reporting on 95 cases. Voiding symptoms (41.1%), pain (40.0%), and acute urinary retention (32.6%) were common presenting features. Urethral calculi were most often initially investigated using plain X-ray (63.2%), with almost all radio-opaque (98.3%). Urethral calculi were frequently associated with coexistent bladder or upper urinary tract calculi (16.8%) and underlying urethral pathology (53.7%) including diverticulum (33.7%) or stricture (13.7%). Urethral calculi were most commonly managed with external urethrolithotomy (31.6%), retrograde manipulation (22.1%), and endoscopic in situ lithotripsy (17.9%). Conclusion: This unique systematic review of urethral calculi provided a summary of clinical features and treatment trends with a suggested treatment algorithm. Management in contemporary urological practice should be according to calculus size, shape, anatomical location, and presence of urethral pathology.

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PURPOSE: To provide a comprehensive review of the current strategies in the management of laryngeal hemangiomas, with an aim to introduce a management algorithm that aligns with the variable clinical presentations and anatomical complexities of these lesions. METHODS: We conducted an extensive literature search across major databases using specific and general terms, combined with Boolean operators, to ensure comprehensiveness. Articles from January 2004 to August 2023 were included, with findings categorized by management approach. RESULTS: Laryngeal hemangiomas exhibit a spectrum of manifestations, ranging from asymptomatic lesions to those causing severe airway obstruction. Optimal management demands an individualized approach tailored to the patient's unique presentation and anatomical considerations. Diverse treatment modalities, each with distinct indications, advantages, and limitations, are explored. Notable highlights encompass the prominent role of Beta-blockers, notably Propranolol, in addressing problematic infantile hemangiomas, the nuanced efficacy of laser therapies contingent upon hemangioma type and depth, and the critical relevance of tracheotomy in emergencies. Novel approaches like transoral robotic surgery and transoral ultrasonic surgery, demonstrate promise in specific scenarios. We propose a management algorithm based on the complexity and presentation of laryngeal hemangiomas, emphasizing individualized treatment strategies, thereby addressing the unique challenges and nuances of each case. CONCLUSION: Laryngeal hemangioma management requires personalized approaches informed by diverse therapies, clinical expertise, and collaboration. The review introduces an algorithm spanning observation to advanced interventions, adapting to each case's complexity. Ongoing research promises innovative treatments.

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Myopia is becoming increasingly common in young generations all over the world, and it is predicted to become the most common cause of blindness and visual impairment in later life in the near future. Because myopia can cause serious complications and vision loss, it is critical to create and prescribe effective myopia treatment solutions that can help prevent or delay the onset and progression of myopia. The scientific understanding of myopia's causes, genetic background, environmental conditions, and various management techniques, including therapies to prevent or postpone its development and slow its progression, is rapidly expanding. However, some significant information gaps exist on this subject, making it difficult to develop an effective intervention plan. As with the creation of this present algorithm, a compromise is to work on best practices and reach consensus among a wide number of specialists. The quick rise in information regarding myopia management may be difficult for the busy eye care provider, but it necessitates a continuing need to evaluate new research and implement it into daily practice. To assist eye care providers in developing these strategies, an algorithm has been proposed that covers all aspects of myopia mitigation and management. The algorithm aims to provide practical assistance in choosing and developing an effective myopia management strategy tailored to the individual child. It incorporates the latest research findings and covers a wide range of modalities, from primary, secondary, and tertiary myopia prevention to interventions that reduce the progression of myopia.

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INTRODUCTION: Odontogenic myxoma is a relatively rare bone tumor involving exclusively the jaws. Despite its benign nature, odontogenic myxoma can exhibit aggressive, locally invasiveness and has a high potential of recurrence. Surgical treatment can be conservative of radical. The choice of surgical procedure is controversial, and there are no established guidelines. CASE SERIES PRESENTATION: We present a case series of three cases of odontogenic myxomas. This case series illustrates the variability of the radioclinical presentation of odontogenic myxoma and the resulting surgical management, ranging from simple enucleation to mandibular interruptive resection surgery with free flap reconstruction. DISCUSSION AND CONCLUSION: Through this case series, we highlighted and described decision criteria contributing to treatment choice and summarized this in an algorithm. Radiological tumor characteristics and also patient specific factors such as age need to be considered to make a personalized decision to each patient.

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Premature ventricular complexes (PVCs) are frequently encountered in clinical practice. The association of PVCs with adverse cardiovascular outcomes is well established in the context of structural heart disease, yet not so much in the absence of structural heart disease. However, cardiac magnetic resonance (CMR) seems to contribute prognostically in the latter subgroup. PVC-induced myocardial dysfunction refers to the impairment of ventricular function due to PVCs and is mostly associated with a PVC burden > 10%. Surface 12-lead ECG has long been used to localize the anatomic site of origin and multiple algorithms have been developed to differentiate between right ventricular and left ventricular outflow tract (RVOT and LVOT, respectively) origin. Novel algorithms include alternative ECG lead configurations and, lately, sophisticated artificial intelligence methods have been utilized to determine the origins of outflow tract arrhythmias. The decision to therapeutically address PVCs should be made upon the presence of symptoms or the development of PVC-induced myocardial dysfunction. Therapeutic modalities include pharmacological therapy (I-C antiarrhythmic drugs and beta blockers), as well as catheter ablation, which has demonstrated superior efficacy and safety.

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Purpose: The purpose of this study is to develop an accessible step-wise management algorithm for the management of pediatric spinal osteoid osteomas (OOs) based on a systematic review of the published literature regarding the diagnostic evaluation, treatment, and outcomes following surgical resection. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric spinal OOs. Data extraction of clinical presentation, management strategies and imaging, and treatment outcomes were performed. Results: Ten studies reporting on 85 patients under the age of 18 years presenting with OOs were identified. Back pain was the most common presenting symptom, and scoliosis was described in 8 out of 10 studies, and radicular pain in 7 out of 10 studies. Diagnostic, intraoperative, and postoperative assessment included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), bone scans, and frozen section. Treatment options varied, including conservative management, open surgical resection with or without intraoperative imaging, and percutaneous image-guided treatment. All included studies described partial or complete resolution of pain in the immediate postoperative period. Conclusions: The proposed algorithm provides a suggested framework for management of pediatric spinal OOs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a step-wise approach should be utilized in the management of pediatric spinal OOs.

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INTRODUCTION: The aim of this study was to compare retinal and choroidal alterations in eyes with severe nonproliferative diabetic retinopathy (NPDR) after panretinal photocoagulation (PRP), using conventional pattern scan laser (PASCAL) and PASCAL with endpoint management (EPM). METHODS: This was a post hoc analysis of a paired randomized clinical trial. Bilateral treatment-naïve eyes of an individual with symmetric severe NPDR were randomly allocated into the threshold PRP group and subthreshold EPM PRP group. Patients had follow-up visits at 1, 3, 6, 9, and 12 months post-treatment. The retinal thickness (RT), choroidal thickness (CT), choroidal area, and choroidal vascularity index (CVI) were compared between the two groups and among different time points within the same group. RESULTS: Seventy eyes of 35 patients with diabetes mellitus (DM) were finally included for analysis at the 6- and 12-month visits, respectively. At 3 and 6 months post-treatment, the RT in the subthreshold EPM PRP group was significantly thinner than that in the threshold PRP group. CT, stromal area, and luminal area were reduced earlier in the threshold PRP group than in the subthreshold EPM PRP group. CVI was not significantly different within the same group or between groups at most time points. CONCLUSION: At 12 months post-treatment, retinal thickening and choroidal disturbance may be slightly less severe and more delayed in eyes receiving PRP using PASCAL with EPM than in those receiving PRP using conventional PASCAL. The EPM algorithm may be a good alternative in PRP when treating severe NPDR. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT01759121.

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BACKGROUND: Chronic pancreatitis (CP) is an inflammatory disease that may be complicated by abdominal pain, pancreatic dysfunction, nutritional deficiencies, and diminished bone density. Importantly, it is also associated with a substantially impaired quality of life and reduced life expectancy. This may partly be explained by suboptimal treatment, in particular the long-term management of this chronic condition, despite several national and international guidelines. Standardization of care through a structured implementation of guideline recommendations may improve the level of care and lower the complication rate of these patients. Therefore, the aim of the present study is to evaluate to what extent patient education and standardization of care, through the implementation of an evidence-based integrated management algorithm, improve quality of life and reduce pain severity in patients with CP. METHODS: The COMBO trial is a nationwide stepped-wedge cluster-randomized controlled trial. In a stepwise manner, 26 centers, clustered in 6 health regions, cross-over from current practice to care according to an evidence-based integrated management algorithm. During the current practice phase, study participants are recruited and followed longitudinally through questionnaires. Individual patients contribute data to both study periods. Co-primary study endpoints consist of quality of life (assessed by the PANQOLI score) and level of pain (assessed by the Izbicki questionnaire). Secondary outcomes include process measure outcomes, clinical outcomes (e.g., pancreatic function, nutritional status, bone health, interventions, medication use), utilization of healthcare resources, (in) direct costs, and the level of social participation. Standard follow-up is 35 months from the start of the trial. DISCUSSION: This is the first stepped-wedge cluster-randomized controlled trial to investigate whether an evidence-based integrated therapeutic approach improves quality of life and pain severity in patients with CP as compared with current practice. TRIAL REGISTRATION: ISRCTN, ISRCTN13042622. Registered on 5 September 2020.

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The authority of user personal health records (PHRs) is usually determined by the owner of a cloud computing system. When a PHR file is accessed, a dynamic access control algorithm must be used to authenticate the users. The proposed dynamic access control algorithm is based on a novel Lagrange interpolation polynomial with timestamps, mainly functioning to authenticate the users with key information. Moreover, the inclusion of timestamps allows user access within an approved time slot to enhance the security of the healthcare cloud system. According to the security analysis results, this healthcare cloud system can effectively resist common attacks, including external attacks, internal attacks, collaborative attacks and equation-based attacks. Furthermore, the overall computational complexity of establishing and updating the polynomials is O(n*m* (log m)2), which is a promising result, where m denotes the degree of $ polynomial~G\left(x, y\right) $ and n denotes the number of secure users in the hierarchy.

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AIM: Ingestion of multiple magnets is increasing these last 15 years in children. They have resulted in numerous reports of serious gastrointestinal complications such as bowel obstruction, ischaemia, necrosis, perforation and fistula formation and even led to death. The increasing number of world-wide reports of complications secondary to magnet ingestion and a frequently delayed diagnosis point to a lack of awareness about these risks among medical care-givers in our country and parents in general. METHODS: We reviewed retrospectively all cases of multiple magnet ingestion that required a gastro-intestinal or surgical procedure for removal from 2009 to 2020. RESULTS: Five children underwent gastroscopy removal and three colonoscopy removal of the magnets. Five patients required surgical (laparotomy or laparoscopy) removal of multiple magnets with intestinal perforations. CONCLUSIONS: We propose an updated management algorithm for multiple magnet ingestion to highlight awareness among primary physicians and parents of the presenting circumstances and symptoms as well as the potential complications associated with multiple magnet ingestion.

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Acanthamoeba keratitis (AK) is a severe cause of infectious keratitis and represents a significant clinical challenge. Recent literature regarding AK epidemiology, diagnosis, treatment modalities, and prognosis is reviewed and synthesized to propose an algorithmic protocol for AK management. Globally, AK outbreaks in developed countries are ongoing, and AK rates have increased. Moreover, current outbreaks may carry a worse prognosis than prior outbreaks. Despite identification of contact lens solutions implicated in AK outbreaks and the consequent market recall of these products, outbreaks persist. Acanthamoeba keratitis afflicts not only refractive soft contact lens users but also cosmetic contact lens users and gas permeable (especially orthokeratology) lens users. Innovations in in vivo confocal microscopy and PCR assays have increased the role for these adjuvant tests alongside corneal smear and culture in a multimodal diagnostic approach to suspected AK. Biguanides (such as chlorhexidine and polyhexamethylene biguanide) and diamidines (propamidine isethionate and hexamidine) remain cornerstones of AK management, and evidence for other treatment modalities continues to evolve. Voriconazole in topical and systemic forms may be useful as adjuvant therapy. The anti-leishmaniasis drug miltefosine, recently given orphan drug status by the United States Food and Drug Administration, has increasing evidence supporting a role in patients with severe/refractory disease. Prior topical corticosteroids have been consistently shown to be associated with worse outcomes in AK. Although not historically thought of as a treatment modality, benzalkonium chloride preservative may be leveraged for its anti-Acanthamoebal properties. The role of Rose-Bengal photodynamic antimicrobial therapy is evolving in selected cases of AK.

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A broken epidural catheter with a retained fragment in the spinal canal is a rare complication of an otherwise low-risk procedure. We present a case of a 37-year-old post-partum female with a fractured epidural catheter with a retained fragment in the epidural space, after epidural anaesthesia using a midline L3/L4 approach. The patient was completely asymptomatic, and the management decision lay between surgical exploration with removal and conservative management with no intervention. CT scan findings were unhelpful, and MRI imaging showed a probable retained fragment penetrating the midline ligamentum flavum, with the catheter tip lying within the spinal canal. The fragment was removed under general anaesthesia 3 days post-delivery. In our proposed treatment algorithm, if the residual catheter fragment is proved radiologically to lie outside the spinal canal and there is no residual catheter breaching the skin to provide a portal for infection, conservative management is reasonable. Early removal is advised when the retained fragment is within the spinal canal-preferably within days to prevent the formation of dural adhesions. This is easier under direct vision, allowing rapid discharge and avoiding much more difficult and higher risk surgery later on.