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Clinical prediction models provide risks of health outcomes that can inform patients and support medical decisions. However, most models never make it to actual implementation in practice. A commonly heard reason for this lack of implementation is that prediction models are often not externally validated. While we generally encourage external validation, we argue that an external validation is often neither sufficient nor required as an essential step before implementation. As such, any available external validation should not be perceived as a license for model implementation. We clarify this argument by discussing 3 common misconceptions about external validation. We argue that there is not one type of recommended validation design, not always a necessity for external validation, and sometimes a need for multiple external validations. The insights from this paper can help readers to consider, design, interpret, and appreciate external validation studies.

Despite the high prevalence of malnutrition in the general inpatient population, there is a lack of knowledge in regard to detecting disease-related malnutrition and implementing nutritional support. Our aim was to suggest practical procedures for screening and treating malnourished or at-risk patients hospitalized in medical wards, thereby fostering a straightforward implementation of nutritional therapy independent of the underlying disease and comorbidities. A working group of experts in clinical nutrition selected and analyzed published disease-specific European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines relevant for our aim. Eight questions in population, intervention, control, outcome format were defined to cover topics such as screening, nutritional targets, and routes of feeding. Individual studies were extracted from the guidelines by applying inclusion and exclusion criteria targeting the heterogeneous population of medical inpatients with or at-risk of disease-related malnutrition. We used those studies as evidence, as well as recommendations from the selected ESPEN guidelines, to formulate answers to the questions. Final agreement with the statement was obtained by consensus of the whole working group. Procedures on how to provide integrated nutritional therapy (oral, enteral, and parenteral) to a heterogeneous patient population were suggested, including how to identify malnourished or at-risk patients, nutrient targets, choice of feeding route, monitoring, and assessment of patients. We also developed a simple algorithm to facilitate the implementation of a nutritional care plan for the general medical inpatient population. By compiling evidence and recommendations from disease-specific guidelines, we were able to suggest a nutritional strategy applicable to large and heterogeneous group of malnourished or at-risk patients admitted to hospitals. A large randomized controlled trial is currently investigating whether this strategy improves clinical outcomes of patients. •There are several guidelines for the nutritional management of specific diseases.•It is challenging to use those guidelines on polymorbid medical inpatients.•A group of experts scrutinised and pooled the evidence behind relevant guidelines.•Procedures to identify and treat malnutrition on medical inpatients were suggested.•A practical algorithm to provide integrated nutritional therapy was developed.

Difficulty falling asleep and/or maintaining sleep are common complaints in patients visiting medical clinics. Insomnia can occur alone or in combination with other medical or psychiatric disorders. Diagnosis and management of insomnia at times are perplexing. This updated study review aimed at a clinical algorithm for diagnosis and treatment of insomnia in adults. We developed an easy-to-apply algorithm to diagnose and manage insomnia that can be used by general practitioners and non-sleep specialists. To this end, our team reviewed the previous studies to determine the prevalence, evaluation, and treatment of insomnia. We used the results to develop a clinical algorithm for diagnosing and managing insomnia. Insomnia occurs in a short (less than 3 months duration) or chronic form (≥3 months duration). Insomnia management includes both pharmacological and non-pharmacological interventions. There is ample research evidence for the impact of a variety of non-pharmacological treatments, but both types of treatments can be used for each patient. If there are any contradictions in the diagnosis process, therapists should use objective instruments, such as polysomnography, but they should not be in a hurry to use these instruments.

Some clinical algorithms incorporate an individual’s race, ethnicity, or both as an input variable or predictor in determining diagnoses, prognoses, treatment plans, or risk assessments. Inappropriate use of race and ethnicity in clinical algorithms at the point of care may exacerbate health disparities and promote harmful practices of race-based medicine. Using database analysis primarily, we identified 42 risk calculators that use race and ethnicity as predictors, five laboratory test results with reference ranges that differed based on race and ethnicity, one therapy recommendation based on race and ethnicity, 15 medications with race- and ethnicity-based initiation and monitoring guidelines, and five medical devices with differential racial and ethnic performances. Information on these clinical algorithms is freely available at https://www.clinical-algorithms-with-race-and-ethnicity.org/ . This resource aims to raise awareness about the use of race and ethnicity in clinical algorithms and track progress toward eliminating their inappropriate use. The database is actively updated to include clinical algorithms that were missed and additional characteristics of these algorithms.

Rapid diagnosis of sudden, unexpected, and potentially fatal complications in the neonatal intensive care unit (NICU) is essential for the initiation of prompt and life-saving management. Point-of-care ultrasound (POCUS) protocols are widely used in adult emergency situations to diagnose and guide treatment, but none has been specifically developed for the neonate. We propose a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU for rapid screening for the most common life-threatening complications needing immediate attention. We integrated current knowledge on the use of POCUS for diagnosis of the most critical neonatal complications into the “SAFE-R protocol” (Sonographic Assessment of liFe-threatening Emergencies — Revised). The ultrasound algorithm was evaluated at the bedside for suitability and ease of use. Main features of SAFE-R are the use of standardized ultrasound points and a simple one-probe rule-in/rule-out approach. The flowchart is designed by order of urgency and priority is given to treatable causes. Hence, ruling out cardiac tamponade is the first step in the decision tree, followed by pneumothorax, pleural effusion, then acute critical aortic occlusion, acute abdominal complications, and severe intraventricular hemorrhage.Conclusion: SAFE-R is the first ultrasound algorithm specifically conceived for use in the NICU to screen for the most common urgent neonatal complications leading to sudden deterioration, thereby providing critical information within minutes. The simplified and rapid approach is designed for the neonatologist and is easy to learn and quick to perform. What is Known:• The fields of neonatal and pediatric critical care are undergoing a transformation with the adoption of POCUS and the recent publication of the first international guidelines on POCUS for critically ill children and neonates.• Targeted emergency ultrasound protocols are widely used in adult emergency and critical care medicine, but specific and adapted ultrasound algorithms are lacking for the pediatric and neonatal population.What is New:• We propose the first targeted ultrasound protocol specifically designed for the suddenly decompensating infant in the NICU for rapid screening of the most common life-threatening complications needing immediate attention.• The SAFE-R ultrasound algorithm integrates current knowledge on ultrasound diagnosis of the most critical neonatal complications into a simple and easy-to-perform emergency scanning protocol aimed to guide initial management and resuscitation efforts.

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/“underfeeding syndrome” and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients.What is Known:• Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice.• The risk of a refeeding syndrome is well known and well managed in severely malnourished patients (“conservative approaches”).What is New:• There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness.• The risks of “underfeeding syndrome” and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding.

Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known:• Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations.What is New:• Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance.• The new classification helps with the targeted management and logical selection of cardiovascular support.

To investigate bone remodelling responses to mandibulectomy, a joint external and internal remodelling algorithm is developed here by incorporating patient-specific longitudinal data. The primary aim of this study is to simulate bone remodelling activity in the conjunction region with a fibula free flap (FFF) reconstruction by correlating with a 28-month clinical follow-up. The secondary goal of this study is to compare the long-term outcomes of different designs of fixation plate with specific screw positioning. The results indicated that the overall bone density decreased over time, except for the Docking Site (namely DS1, a region of interest in mandibular symphysis with the conjunction of the bone union), in which the decrease of bone density ceased later and was followed by bone apposition. A negligible influence on bone remodeling outcome was found for different screw positioning. This study is believed to be the first of its kind for computationally simulating the bone turn-over process after FFF maxillofacial reconstruction by correlating with patient-specific follow-up.

Study Design Narrative Review. Objective Contextualized by a narrative review of recent literature, we propose a wound complication prevention and management algorithm for spinal oncology patients. We highlight available strategies and motivate future research to identify optimal and individualized wound management for this population. Methods We conducted a search of recent studies (2010-2022) using relevant keywords to identify primary literature in support of current strategies for wound complication prevention and management following spine tumor surgery. When primary literature specific to spine tumor cases was not available, data were extrapolated from studies of other spine surgery populations. Results were compiled into a proposed clinical algorithm to guide practice considering available evidence. Results Based on available literature, we recommend individualized stratification of patients according to identifiable risk factors for wound complication and propose several interventions which might be employed preventatively, including intrawound antibiotic administration, negative pressure wound therapy, and primary flap closure of the surgical wound. Of these, the available evidence, weighing possible risks vs benefits, most strongly favors primary flap closure of surgical wounds, particularly for patients with multiple risk factors. A secondary algorithm to guide management of wound complications is also proposed. Conclusions Wound complications such as SSI and dehiscence remain a significant source of morbidity following spine tumor surgery. Triaging patients on an individualized basis according to risk factors for complication may aid in selecting appropriate prophylactic strategies to prevent these complications. Future research in this area is still needed to strengthen recommendations.

There is no firm consensus about the optimal technique for the administration of exogenous surfactant in preterm neonates, and different techniques may be equally effective. The intubation-surfactant-extubation (INSURE) procedure has not been fully described, and important details, such as duration and mode of ventilation, remain unclear, leading to significant clinical practice variations and influencing its suitability and feasibility. Since the first INSURE description, our knowledge in respiratory care has largely progressed, but the technique has not been updated according to current evidence-based practice. Thus, our aim is to formally describe a modern way to perform INSURE, based on the current knowledge and technology, to increase its feasibility and patients’ safety. We offer ENSURE (Enhanced INSURE) as an updated and standardised technique for surfactant administration, clarifying crucial issues of the original method by applying current state-of-the-art concepts of respiratory care. We performed a cross-sectional observational study enrolling 57 preterm neonates describing ENSURE feasibility and safety. Conclusion: ENSURE can be used as a reference technique in clinical practice, teaching and research. What is Known:• There is no consensus about the optimal method for surfactant administration. INSURE technique has been originally described many years ago without considering modern principles of neonatal respiratory care and the available state-of-the-art technology.What is New:• We here describe a modern way to perform INSURE, based on the current knowledge and technology. We called it ENSURE (Enhanced INSURE) and clarified crucial points of the original technique, in light of the current knowledge. We verified feasibility and safety of ENSURE in a cross-sectional observational study enrolling 57 preterm neonates.