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* Context.--United States' clinical practice guidelines (CPGs) are often produced by professional societies and used worldwide in daily medical practice. However, studies in various medical specialties demonstrate under-representation of women and racial and ethnic minority groups in CPGs. The representation of authors by gender, race, and ethnicity of US pathology CPGs has not been previously evaluated. Objective.--To assess if women and individuals from racial and ethnic minority groups are underrepresented as authors of pathology CPGs. Design.--The gender, race, ethnicity, and terminal degrees of authors of 18 CPGs from the College of American Pathologists were coded by using photographs and other available information online and compared to their representation in academic pathology per Association of American Medical Colleges benchmark data. Results.--Two hundred seventy-five author positions (202 physician author positions) were analyzed. Women overall (119 of 275; 43.3%) and women physicians (65 of 202; 32.2%) held fewer positions than all men and men physicians. Women physicians were significantly underrepresented in physician author positions, while White men physicians were significantly overrepresented in all, first, senior, and corresponding authorship roles when compared to the proportion of women and White men physicians among pathology faculty, respectively. Asian men and women physicians were underrepresented as compared to their representation among pathology faculty. Conclusions.--Men, particularly White men physicians, are overrepresented among pathology CPG author positions, while women physicians and some physicians from racial and ethnic minority groups are underrepresented. Further research is needed to understand the impact of these findings on the careers of underrepresented physicians and the content of guidelines. (Arch Pathol Lab Med. 2024;148:230-241; doi: 10.5858/arpa.2022-0351-OA), Clinical practice guidelines (CPGs) influence the daily practice of medicine. In the United States, guidelines are often produced by professional societies and used around the world. As such, they have [...]

* Context.--The pathologic diagnosis of usual interstitial pneumonia (UIP) remains a challenging area, and application of histologic UIP guidelines has proved difficult. Objective.--To understand current practice approaches by pulmonary pathologists for the histologic diagnosis of UIP and other fibrotic interstitial lung diseases (ILDs). Design.--The Pulmonary Pathology Society (PPS) ILD Working Group developed and sent a 5-part survey on fibrotic ILD electronically to the PPS membership. Results.--One hundred sixty-one completed surveys were analyzed. Of the respondents, 89% reported using published histologic features in clinical guidelines for idiopathic pulmonary fibrosis (IPF) in their pathologic diagnosis; however, there was variability in reporting terminology, quantity and quality of histologic features, and the use of guideline categorization. Respondents were very likely to have access to pulmonary pathology colleagues (79%), pulmonologists (98%), and radiologists (94%) to discuss cases. Half of respondents reported they may alter their pathologic diagnosis based on additional clinical and radiologic history if it is pertinent. Airway-centered fibrosis, granulomas, and types of inflammatory infiltrates were considered important, but there was poor agreement on how these features are defined. Conclusions.--There is significant consensus among the PPS membership on the importance of histologic guidelines/features of UIP. There are unmet needs for (1) consensus and standardization of diagnostic terminology and incorporation of recommended histopathologic categories from the clinical IPF guidelines into pathology reports, (2) agreement on how to incorporate into the report relevant clinical and radiographic information, and (3) defining the quantity and quality of features needed to suggest alternative diagnoses. (Arch Pathol Lab Med. 2024;148:168-177; doi: 10.5858/arpa.2022-0530-OA), The histologic features of usual interstitial pneumonia (UIP), the fibrotic interstitial lung disease (ILD) pattern seen in, but not limited to, clinical idiopathic pulmonary fibrosis (IPF), was first described by [...]

Background Infants with chronic kidney disease (CKD) form a vulnerable population who are highly prone to mineral and bone disorders (MBD) including biochemical abnormalities, growth retardation, bone deformities, and fractures. We present a position paper on the diagnosis and management of CKD-MBD in infants based on available evidence and the opinion of experts from the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. Methods PICO (Patient, Intervention, Comparator, Outcomes) questions were generated, and relevant literature searches performed covering a population of infants below 2 years of age with CKD stages 2-5 or on dialysis. Clinical practice points (CPPs) were developed and leveled using the American Academy of Pediatrics grading matrix. A Delphi consensus approach was followed. Results We present 34 CPPs for diagnosis and management of CKD-MBD in infants, including dietary control of calcium and phosphate, and medications to prevent and treat CKD-MBD (native and active vitamin D, calcium supplementation, phosphate binders). Conclusion As there are few high-quality studies in this field, the strength of most statements is weak to moderate, and may need to be adapted to individual patient needs by the treating physician. Research recommendations to study key outcome measures in this unique population are suggested. Graphical Abstract, Author(s): Justine Bacchetta [sup.1] [sup.2] [sup.3] , Claus Peter Schmitt [sup.4] , Sevcan A. Bakkaloglu [sup.5] , Shelley Cleghorn [sup.6] , Maren Leifheit-Nestler [sup.7] , Agnieszka Prytula [sup.8] , Bruno [...]

Background: In their 2019 guideline on the prescribing and management of opioids after elective ambulatory thoracic surgery, the Canadian Association of Thoracic Surgeons (CATS) recommended 120 morphine milligram equivalents (MME) after minimally invasive (video-assisted thoracoscopic surgery [VATS]) lung resection. We conducted a quality-improvement project to optimize opioid prescribing after VATS lung resection. Methods: We assessed baseline prescribing practices for opioid-naive patients. Using a mixed-methods approach, we selected 2 quality-improvement interventions: formal incorporation of the CATS guideline into our postoperative care pathway, and development of a patient information handout regarding opioids. The intervention was initiated on Oct. 1, 2020, and was formally implemented on Dec. 1, 2020. The outcome measure was average MME of discharge opioid prescriptions, the process measure was proportion of discharge prescriptions exceeding the recommended dosage, and the balancing measure was opioid prescription refills. We analyzed the data using control charts, and compared all measures between the pre-intervention (12 mo before) and postintervention (12 mo after) groups. Results: A total of 348 patients who underwent VATS lung resection were identified, 173 before the intervention and 175 after the intervention. Significantly less MME was prescribed after the intervention (100 v. 158, p < 0.001), and a lower proportion of prescriptions were nonadherent to the guideline (18.9% v. 50.9%, p < 0.001). Control charts showed special cause variation corresponding with the intervention, and system stability existed after the intervention. There was no statistically significant difference in the proportion or dosage of opioid prescription refills after the intervention. Conclusion: After implementation of the CATS opioid guideline, there was a significant reduction in opioids prescribed at discharge and no increase in opioid prescription refills. Control charts are a valuable resource for monitoring outcomes on an ongoing basis and for assessing the effects of an intervention. Contexte: La ligne directrice de l'Association canadienne de chirurgie thoracique (ACCT) sur la prescription et la prise en charge des opioïdes après une chirurgie thoracique ambulatoire non urgente, publiée en 2019, recommande 120 mg d'équivalent morphine par jour (EMJ) à la suite d'une résection pulmonaire à effraction minimale (chirurgie thoracique vidéo-assistée, CTVA). Nous avons mené un projet d'amélioration de la qualité pour optimiser la prescription d'opioïdes après cette opération. Méthodes: Nous avons évalué les pratiques de prescription initiales chez des patients n'ayant jamais pris d'opioïdes. Avec une approche de méthodes mixtes, nous avons sélectionné 2 interventions d'amélioration de la qualité : l'intégration officielle de la ligne directrice de l'ACCT à notre parcours de soins postopératoires et l'élaboration d'un document d'information sur les opioïdes à l'intention des patients. L'intervention a démarré le 1er octobre 2020 et a été officiellement mise en oeuvre le 1er décembre 2020. L'indicateur de résultat était l'?‰MJ moyen des ordonnances d'opioïdes au moment du congé; l'indicateur de processus était la proportion d'ordonnances au moment du congé dépassant la posologie recommandée; et l'indicateur d'équilibre était le nombre de renouvellements d'ordonnances d'opioïdes. Nous avons analysé les données avec des cartes de contrôle et avons comparé tous les indicateurs entre les groupes préintervention (12 mois avant) et postintervention (12 mois après). Résultats : Nous avons répertorié un total de 348 patients ayant subi une résection pulmonaire par CTVA, 173 avant l'intervention et 175 après. L'?‰MJ prescrit était significativement inférieur après l'intervention (100 mg c. 158 mg, p < 0,001) et une proportion moindre des ordonnances ne respectaient pas la ligne directrice (18,9% c. 50,9%, p < 0,001). Les cartes de contrôle ont montré une variation due à des causes spéciales correspondant à l'intervention et une stabilité du système après celle-ci. Nous n'avons observé aucune différence statistiquement significative pour la proportion ou la posologie des renouvellements d'ordonnances d'opioïdes après l'intervention. Conclusion : La mise en oeuvre de la ligne directrice de l'ACCT sur les opioïdes a été suivie d'une diminution importante des opioïdes prescrits au moment du congé et de renouvellements d'ordonnances d'opioïdes inchangés. Les cartes de contrôle sont une ressource utile pour la surveillance des résultats en continu et l'évaluation des effets d'une intervention., Canada is currently experiencing a crisis of opioid misuse. In 2016, there were 2861 apparent opioid-related deaths in the country, and, on average, 16 patients were admitted to hospital daily [...]

The modern management of rectal cancers continues to evolve. With the release of data from new landmark randomized controlled trials (RAPIDO, PRODIGE-23), total neoadjuvant therapy (TNT) has moved to the forefront of locally advanced rectal cancer treatment and is considered a standard option in selected patients. Total neoadjuvant therapy promises enhanced systemic disease control, better treatment adherence and less time with an ostomy. However, TNT as currently described encompasses a number of different potential treatment options that differ significantly in terms of their radiation dosage, chemotherapy regimen and order of treatments administered. Being familiar with TNT regimens will be important for rectal cancer surgeons to appropriately advocate for their patients and optimize their outcomes. This article serves as a primer for the general surgeon and offers a pragmatic overview of the indications, realistic expected benefits and potential downsides of each TNT regimen., For 15 years, the standard of care for locally advanced (clinical T3-4 or N-positive) rectal cancer in North America has consisted of neoadjuvant therapy (radiation or chemoradiotherapy) followed by total [...]

We sought to compare success and re-tear rates of surgically treated full-thickness tears of the rotator cuff in men and women older than 18 years of age to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and superior capsular reconstruction (SCR); and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking surgical intervention of full thickness rotator cuff tears by improving counselling on surgical treatment options and outcomes. It will also benefit surgical providers by expanding their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. Nous avons voulu comparer les taux de succes de la reparation chirurgicale d'une rupture transfixiante de la coiffe des rotateurs et les taux de rupture iterative chez les hommes et les femmes de plus de 18 ans pour concevoir un guide destine aux chirurgiens orthopedistes et autres prestataires de soins de sante qui evaluent, conseillent et traitent ces patients. Pour ce faire, nous avons effectue des recherches dans les bases de donnees Medline, Embase et Cochrane jusqu'au 20 avril 2021, et avons retenu tous les essais randomises publies en anglais portant sur : l'efficacite comparee de la reparation arthroscopique a simple rang et a double rang; l'efficacite du transfert du muscle grand dorsal comparativement a la reparation partielle de la coiffe des rotateurs, au transfert du trapeze inferieur et a la reconstruction capsulaire superieure; et une comparaison de la reparation precoce et tardive de la coiffe des rotateurs a la suite d'une rupture traumatique. Nous avons aussi retenu les etudes observationnelles comparant le transfert du muscle grand dorsal au transfert du trapeze inferieur et a la reparation partielle, ainsi que les etudes comparant le traitement precoce et tardif des ruptures traumatiques de la coiffe des rotateurs. Les parametres d'interet etaient la capacite fonctionnelle, la douleur et le taux de rupture iterative associes a ces interventions. Nous avons evalue la qualite des donnees probantes et la force des recommandations a l'aide de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Ce guide beneficiera aux patients ayant besoin d'une intervention chirurgicale pour une rupture transfixiante de la coiffe des rotateurs en offrant de meilleurs conseils sur les options de traitement chirurgical et leurs resultats. Il aidera aussi les chirurgiens a acquerir des connaissances sur les differentes approches chirurgicales. Les donnees presentees pourront etre utilisees pour mettre au point des cadres et outils favorisant la prise de decision partagee., Degenerative tearing of the rotator cuff is one of the most common disorders of the shoulder. (1,2) Rotator cuff tears may result in considerable pain, typically experienced over the lateral [...]

Background: Injury severity scales have traditionally been used to assess the perform ance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. Methods: Based on a list of potential participants we obtained using data on training, experience, geographic location, affliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. Results: Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. Conclusion: We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools. Contexte : Les echelles de gravite des blessures sont habituellement utilisees pour evaluer les performances des protocoles de triage prehospitalier des traumatismes, mais elles sont inadaptees aux besoins urgents des interventions specialisees en traumatologie. La presente etude visait a concevoir une liste des interventions hospitalieres urgentes et specialisees en traumatologie necessitant un transport direct vers le centre de traumatologie du niveau le plus eleve de la circonscription hospitaliere. Methodes : Nous avons constitue une liste de participants potentiels d'apres des donnees sur la formation, l'experience, l'emplacement geographique, les affliations et le poste au sein d'etablissements majeurs en traumatologie pour recruter differents experts en traumatologie (dont des professionnels des soins prehospitaliers, des soins d'urgence, des soins intensifs et de la chirurgie, des epidemiologistes ainsi que des cliniciens decideurs) de tout le Canada a qui nous avons demande de remplir un questionnaire Delphi modife en 3 etapes. Nous avons effectue une revue de la litterature des criteres utilises pour definir les soins urgents et specialises en traumatologie et avons inclus l'ensemble des interventions diagnostiques et therapeutiques decrites dans les etudes precedentes a la liste des interventions presentees aux panelistes. Notre comite consultatif, 5 professionnels de la sante connaissant bien la traumatologie, s'est entendu sur la liste definitive. Les participants ont note la classification potentielle de 38 elements comme des interventions urgentes et specialisees en traumatologie sur une echelle de Likert en 9 points. Les interventions moderement ou fortement approuvees par plus de 67 % des participants (7-9 sur l'echelle de Likert) ont ete retenues, tandis que celles qui n'ont pas abouti a un consensus ont ete presentees a nouveau a l'etape suivante. Resultats : Vingt-trois panelistes ont ete recrutes et ont ete 91 %, 96 % et 83 % a repondre a chaque etape du sondage. A l'issue du processus Delphi, 30 des 38 interventions, dont l'intubation tracheale, l'administration de produits sanguins et l'angioembolisation, ainsi que les chirurgies abdominales, thoraciques, neurochirurgicales, orthopediques et du rachis (a l'exclusion de la chirurgie de la hanche ou des membres et l'amputation des orteils ou des doigts) ont ete selectionnees. L'hospitali sa tion en soins intensifs ou pour observation d'un traumatisme cranien, medullaire, tho ra cique ou abdominal a aussi ete retenue. Conclusion : Nous avons elabore une liste canadienne par consensus des interventions hospitalieres urgentes et specialisees en traumatologie necessitant un transport direct vers un grand centre de traumatologie afin de normaliser les evaluations des protocoles actuels pour en tirer de nouveaux outils de triage., Trauma is the leading cause of mortality, morbidity and health-related productivity loss among young adults and carries an estimated annual cost of $27 billion in Canada. (1) For critically injured [...]

Author(s): David W. Brossier [sup.1], Lyvonne N. Tume [sup.2], Anais R. Briant [sup.3], Corinne Jotterand Chaparro [sup.4] [sup.5], Clémence Moullet [sup.4], Shancy Rooze [sup.6], Sascha C. A. T. Verbruggen [sup.7], [...]