Background After the COVID-19 pandemic and ageing populations significantly strained hospital capacity, the case for building capacity to safely treat acutely ill patients in alternative settings has never been clearer. Hospital inpatient costs also account for one-third of US healthcare expenditures and continue to rise, while patients increasingly prefer receiving care at home. As studies continue to demonstrate the safety and effectiveness of managing certain acute medical conditions in settings outside the hospital, it is important to better understand the factors that facilitate this healthcare transformation.Methods Through a narrative review of the literature, we sought to identify critical factors in the development of substitutive management strategies to inpatient hospitalisation across various acute conditions. In a modified Delphi process, we identified and organised these factors into a unified conceptual framework to further enable healthcare delivery redesign and better align patient need with the setting of care.Results We identified 14 critical factors that enabled patients to be managed using substitutive acute care strategies. A conceptual framework was then generated based on the following schema: (1) qualifying acute condition(s); (2) substitutive care delivery setting(s); (3) technological capabilities; (4) payment model, regulations and liability; (5) patient, family and clinician experience of care and (6) identification of eligible patient population.Conclusion A comprehensive understanding of these critical factors and the application of this conceptual framework can further enable the development of successful, high-quality substitutive management strategies to inpatient hospitalisation.
Objective To characterize contemporary management strategies and reconstructive techniques for frontal bone osteoradionecrosis (ORN) following anterior skull base surgery and radiation therapy (RT). Design Retrospective case series. Setting Tertiary academic medical center. Participants Patients who underwent craniotomies for anterior skull base tumors between 2008 and 2023 and received postoperative RT. Main Outcome Measures Incidence, timing, and management of frontal bone ORN, including reconstructive approaches and surgical outcomes. Results Among 39 patients meeting inclusion criteria, 7 (18%) developed frontal bone ORN after anterior skull base surgery and radiation. All affected patients received adjuvant radiation with a mean cumulative dose of 67.2 Gy (range, 62.4-69.6). ORN was diagnosed at a mean of 28.7 months (range, 2-78) following completion of radiation therapy. Five patients (71%) underwent surgical intervention, which universally included debridement and hardware removal. Reconstructive strategies comprised temporalis muscle flap (20%), titanium cranioplasty (60%), free flap reconstruction (60%), and custom-designed cranial implants (60%). Primary free flaps included radial forearm (n = 2) and latissimus dorsi (n = 1), with two patients later requiring anterolateral thigh flaps. Median follow-up was 10 years (range, 6.7-14.3), during which patients underwent a median of 2.5 reconstructive procedures (range, 0-6). Conclusion Management of frontal bone ORN often requires complex revision cranioplasty and free flap reconstruction. Most patients required multiple surgeries to achieve stable wound healing, underscoring the importance of early recognition and consideration of prophylactic strategies in high-risk, irradiated patients. Level of Evidence 4.
AIM The "2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia" retires and replaces the "2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol." METHODS A comprehensive literature search was conducted from October 2024 to December 2024 to identify clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE The focus of this clinical practice guideline is to address the evaluation, management, and monitoring of individuals with dyslipidemias, including high blood cholesterol, hypertriglyceridemia, and elevated lipoprotein(a).
Background There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.Methods Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (>= 75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.Results This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.Conclusions In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.
End-to-end automation of realistic healthcare operations stresses three capabilities underrepresented in current benchmarks: policy density, decisions must be grounded in a large library of medical, insurance, and operational rules; Multi-role composition: a single task requires the agent to play multiple roles with handoffs; and multilateral interaction: intermediate workflow steps are multi-turn dialogs, such as peer-to-peer review and patient outreach. We introduce χ-Bench, a benchmark of long-horizon healthcare workflows across three domains: provider prior authorization, payer utilization management, and care management. Each task hands the agent a clinical case in a high-fidelity simulator of 20 healthcare apps exposed via 87 MCP tools, which it must drive to a terminal status through tool calls and writing the role's artifacts, guided by a 1,290+ document managed-care operations handbook skill. Across 30 agent harness/models configurations, the best agent resolves only 28.0
