Aktueller Newsletter

Profile of lacosamide and its role in the long-term treatment of epilepsy: a perspective from the updated NICE guideline.

Neuropsychiatr Dis Treat. 2013;9:467-76

Authors: Nunes VD, Sawyer L, Neilson J, Sarri G, Cross JH

Abstract
AIM: The goal of antiepileptic treatment is to achieve seizure freedom or seizure control. The aim of this paper is to review the evidence for the use of lacosamide for adjunctive treatment of refractory focal seizures with or without secondary generalization, within the scope of the 2012 update of the Clinical Guideline published by the National Institute for Health and Clinical Excellence (NICE).
METHODS: Clinical evidence for the use of lacosamide and other antiepileptic drugs (AEDs) was systematically reviewed, evaluated, and presented to the Guideline Development Group. Only randomized clinical trials were included. Outcomes of clinical efficacy (seizure freedom, 50% reduction in seizure frequency, time to first seizure, time to 12-month remission, treatment withdrawal, and time to treatment withdrawal), experience of adverse events, and cognitive and quality of life outcomes were reviewed. A decision model was built to weigh the clinical benefits of each adjunctive AED, measured by seizure control and seizure reduction, compared with the harm from adverse events, as measured by withdrawals from treatment due to adverse events.
RESULTS: Lacosamide was included as part of the recommended AEDS to be used in tertiary epilepsy centers. The evidence review showed that more participants who received lacosamide as an adjunctive treatment had at least a 50% reduction in seizure frequency compared with those taking placebo. However, more participants on lacosamide were found to experience adverse events and withdrawal from treatment compared with those on placebo. The cost-effectiveness analysis showed that compared with placebo, the benefits gained from adjunctive lacosamide were modest and uncertain, whereas the costs were significantly high. Compared with other AEDs licensed for adjunctive therapy in focal seizures, lacosamide was associated with fewer quality-adjusted life years and higher costs. Therefore, the Guideline Development Group noted that the balance of benefit and harm needs to be carefully monitored in all patients.

PMID: 23630422 [PubMed - in process]

The New AJCC Guidelines in Practice: Utility of the MITF Immunohistochemical Stain in the Evaluation of Single-cell Metastasis in Melanoma Sentinel Lymph Nodes.

Am J Surg Pathol. 2013 Apr 25;

Authors: Hutchens KA, Heyna R, Mudaliar K, Wojcik E

Abstract
The American Joint Commission on Cancer 2010 guideline changes recommend all patients with single-cell melanoma metastasis identified by immunhistochemical staining of sentinel lymph nodes to be classified as N1 stage. In this study we evaluated the utility of adding microphthalmia transcription factor (MITF) to our current sentinel node evaluation protocol. Twenty benign lymph nodes from nonmelanoma patients were stained with MITF, MART-1/Melan-A, and HMB-45. Hematoxylin and eosin-stained and immunohistochemically stained slides were assessed for the frequency of positive staining, pattern and location of staining, and for the presence of pigment within the node. Fifteen of 20 (75%) lymph nodes evaluated showed >1 cell staining with MITF in variable locations and patterns throughout the lymph node. MART-1/Melan-A-positive cells were identified in 4 of 20 cases (20.0%), mostly in the sinusoidal location (3/4). Fifty percent (10/20) of the lymph nodes contained cells that stained positive for HMB-45. Nine of 10 of the HMB-45-positive cells were in a sinusoidal location corresponding to easily discernible pigmented histiocytes. We conclude that MITF stains nonmelanocytic cells in benign lymph nodes 75% of the time. MITF has a much higher rate of positive staining in benign lymph nodes compared with MART-1/Melan-A, which had positive staining only 20% of the time. MITF showed 2 different staining patterns, type A and type B. Both patterns could be difficult to distinguish from true metastasis, and thus adding MITF to sentinel node evaluation panels is not helpful and may be histologically vexing.

PMID: 23629445 [PubMed - as supplied by publisher]

Quality of Care of People With Type 2 Diabetes in Eight European Countries: Findings from the Guideline Adherence to Enhance Care (GUIDANCE) study.

Diabetes Care. 2013 Apr 29;

Authors: Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C, Nolan J, Pazderska A, Rutten G, Trento M, Khunti K, On behalf of the GUIDANCE Study Group

Abstract
OBJECTIVESWe sought to determine levels of adherence in eight European countries to recommendations for the management of type 2 diabetes and to investigate factors associated with key intermediate outcomes.RESEARCH DESIGN AND METHODSGUIDANCE was a cross-sectional study including retrospective data extraction from the medical records of people with type 2 diabetes recruited, using a shared protocol, from primary and specialist care sites in the following eight European countries: Belgium, France, Germany, Italy, Ireland, Sweden, the Netherlands, and the United Kingdom. The dataset for analysis comprised 7,597 cases. Proportions meeting process and outcome criteria were determined, including between-country variations. Logistic regression was used to investigate potential predictors of meeting targets for HbA1c, blood pressure, and LDL cholesterol.RESULTSIn the total sample, adherence to process recommendations was high for some measures, for example, HbA1c recorded in past 12 months in 97.6% of cases. Target achievement for intermediate outcome measures was lower, with only 53.6% having HbA1c <7%. Considerable between-country variation was identified for both processes and outcomes. The following characteristics were associated with an increased likelihood of meeting targets for all three measures considered (HbA1c, blood pressure, LDL cholesterol): shorter diagnosis of diabetes; having one or more macrovascular complications; lower BMI; being prescribed lipid-lowering medication; and no current antihypertensive prescribing.CONCLUSIONSCompared with earlier reports, we have suggested some encouraging positive trends in Europe in relation to meeting targets for the management of people with type 2 diabetes, but there is still scope for further improvement and greater between-country consistency.

PMID: 23628621 [PubMed - as supplied by publisher]

Practical Guide to Understanding the Need for Clinical Practice Guidelines.

Otolaryngol Head Neck Surg. 2013 Apr 26;

Authors: Neely JG, Graboyes E, Paniello RC, Sequeira SM, Grindler DJ

Abstract
With recent changes in the landscape of health care, clinical practice guidelines (CPGs) have proliferated. Attitudes about guidelines differ considerably, forming 2 competing viewpoints with considerable tension between them. Some feel CPGs are unneeded or are efforts to create automated "cookie cutter" medical practice; at best, they are perceived as suggestions that may be altered by experience. Others feel they are mandates that must be followed to the letter. This article attempts to explain how and why we have arrived at this point and to explain the origins of the differing viewpoints. We begin by describing the 2 viewpoints and proceed to define the origin of medicine as a profession and to chronicle the evolution of health insurance, medical education, and scientific methods for evaluating evidence.

PMID: 23625796 [PubMed - as supplied by publisher]

Italian Cardiological Guidelines for Sports Eligibility in Athletes with Heart Disease: Part 2.

J Cardiovasc Med (Hagerstown). 2013 Apr 25;

Authors: Biffi A, Delise P, Zeppilli P, Giada F, Pelliccia A, Penco M, Casasco M, Colonna P, D'Andrea A, D'Andrea L, Gazale G, Inama G, Spataro A, Villella A, Marino P, Pirelli S, Romano V, Cristiano A, Bettini R, Thiene G, Furlanello F, Corrado D

Abstract
In Italy the existence of a law on health protection of competitive sports since 1982 has favored the creation and the revision of these cardiological guidelines (called COCIS), which have reached their fourth edition (1989-2009). The present article is the second English version, which has summarized the larger version in Italian. The experience of the experts consulted in the course of these past 20 years has facilitated the application and the compatibility of issues related to clinical cardiology to the sports medicine field. Such prolonged experience has allowed the clinical cardiologist to acquire knowledge of the applied physiology of exercise and, on the other hand, has improved the ability of sports physicians in cardiological diagnostics. All this work has produced these guidelines related to the judgment of eligibility for competitive sports in the individual clinical situations and in the different cardiovascular abnormalities and/or heart disease. Numerous arguments are debated, such as interpretation of the athlete's ECG, the utility of a preparticipation screening, arrhythmias, congenital heart disease, cardiomyopathies, arterial hypertension, ischemic heart disease and other particular issues.

PMID: 23625056 [PubMed - as supplied by publisher]

Appropriate use criteria for amyloid PET imaging cannot replace guidelines: On behalf of the European Association of Nuclear Medicine.

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Eur J Nucl Med Mol Imaging. 2013 Apr 26;

Authors: Booij J, Arbizu J, Darcourt J, Hesse S, Nobili F, Payoux P, Pappatà S, Tatsch K, Walker Z, Pagani M

Abstract

PMID: 23619939 [PubMed - as supplied by publisher]

[Adherence to guidelines for the treatment of venous thromboembolism in cancer patients: A retrospective analysis of 145 cases.]

Related Articles

J Mal Vasc. 2013 Apr 22;

Authors: Belhadj Chaidi R, Thollot C, Ferru A, Roblot P, Landron C

Abstract
OBJECTIVES: To assess adherence to French guidelines for curative treatment of thromboembolism in cancer patients, and to identify factors limiting their implementation. PATIENTS AND METHODS: Retrospective analysis of the medical files of cancer patients diagnosed with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in one site between January 1st, 2010 and June 30th, 2011. Central venous catheter thrombosis and superficial vein thrombosis were excluded. RESULTS: The series included 145 patients, among whom 113 (78%) had solid tumors (at a metastatic stage in 68% of cases) and 33 (22%) had hematologic malignancies. Low molecular weight heparin (LMWH) was prescribed as long-term treatment (>10days) for 83 patients (57.2%) and a vitamin K antagonist (VKA) for 33 patients (22.7%). Bleeding required treatment modifications or discontinuation in 11 (7.5%) and 10 (6.8%) patients respectively. After 6months, LMWH, VKA and fondaparinux were prescribed for 28, 27 and six (19.3%, 18.6% et 4.1%) patients respectively. Mean duration of anticoagulation was 176.8days. Treatment was not affected by a history of venous thromboembolism, the presence of pulmonary embolism or proximal deep vein thrombosis but it was significantly shorter in case of thrombosis limited to muscular veins (115.5 vs 182.3days, P<0.05). Overall, guidelines were fully implemented in only 68 (46.9%) patients, with regards to the choice of pharmacological class and duration of treatment. CONCLUSION: Adherence to national guidelines is insufficient and actions must be taken to improve the management of venous thromboembolism in cancer patients.

PMID: 23619202 [PubMed - as supplied by publisher]

Italian Cardiological Guidelines for Sports Eligibility in Athletes with Heart Disease: Part 1.

Related Articles

J Cardiovasc Med (Hagerstown). 2013 Apr 23;

Authors: Biffi A, Delise P, Zeppilli P, Giada F, Pelliccia A, Penco M, Casasco M, Colonna P, D'Andrea A, D'Andrea L, Gazale G, Inama G, Spataro A, Villella A, Marino P, Pirelli S, Romano V, Cristiano A, Bettini R, Thiene G, Furlanello F, Corrado D

Abstract
In Italy the existence of a law on health protection of competitive sports since 1982 has favored the creation and the revision of these cardiological guidelines (called COCIS), which have reached their fourth edition (1989-2009). The present article is the second English version, which has summarized the larger version in Italian. The experience of the experts consulted in the course of these past 20 years has facilitated the application and the compatibility of issues related to clinical cardiology to the sports medicine field. Such prolonged experience has allowed the clinical cardiologist to acquire knowledge of the applied physiology of exercise and, on the other hand, has improved the ability of sports physicians in cardiological diagnostics. All this work has produced these guidelines related to the judgment of eligibility for competitive sports in the individual clinical situations and in the different cardiovascular abnormalities and/or heart disease. Numerous arguments are debated, such as interpretation of the athlete's ECG, the utility of a preparticipation screening, arrhythmias, congenital heart disease, cardiomyopathies, arterial hypertension, ischemic heart disease and other particular issues.

PMID: 23615077 [PubMed - as supplied by publisher]

Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy.

Related Articles

Pediatr Emerg Care. 2013 Apr 22;

Authors: Russell WS, Schuh AM, Hill JG, Hebra A, Cina RA, Smith CD, Streck CJ

Abstract
OBJECTIVES: The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging. METHODS: A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation. RESULTS: Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation. CONCLUSIONS: Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

PMID: 23611916 [PubMed - as supplied by publisher]

Reducing the costs of paediatric antibiotic prescribing in the community by implementing guideline recommendations.

J Clin Pharm Ther. 2013 Apr 24;

Authors: Piovani D, Clavenna A, Sequi M, Cartabia M, Bortolotti A, Fortino I, Merlino L, Bonati M, PeFAB group

Abstract
WHAT IS KNOWN AND OBJECTIVE: Italian children receive a high number of antibiotic prescriptions, and the use of second-choice antibiotics is common. A few studies in other countries have demonstrated that the implementation of international guidelines for the most common paediatric diseases may reduce the associated costs. A cost analysis of the expenditure for antibiotic prescriptions in outpatient children in the Lombardy region (Italy) and for each of the region's local health units (LHUs) was performed using a pharmacoepidemiological approach. The safety and cost impact associated with a quali-quantitative improvement in antibiotic prescribing was estimated. METHODS: The data source was the Lombardy region's prescription database (year 2008) for outpatient children <14 years old. The average total expenditure for each package, and per capita, was calculated for each active substance considered and for each LHU. An estimate of the possible cost reduction was elaborated using, as a reference, the prescription profile of a group of paediatricians that has been involved in initiatives concerning care for years. The hospital admission rates for acute respiratory infections (ARI) and their major complications were evaluated at the regional level and in the group of children followed by the reference paediatricians. RESULTS AND DISCUSSION: The cost reduction estimate reveals a possible decrease in antibiotic expenditure of about 3·6 million euros (-19·5%) in the Lombardy region. Large variability was observed between different LHUs (-33·3 to +9·2% of difference). The hospital admission rate was not different when comparing the group of children followed by the reference paediatricians to the rest of the study population, but the hospital admission rate for ARI was lower in the reference group (χ(2) = 16·4, P < 0·001). WHAT IS NEW AND CONCLUSION: This is the first Italian study to evaluate the costs related to a specific prescription profile, which already exists in the real setting, hypothesizing its application in a large outpatient child population of the same geographical area. The results show that by improving prescribing appropriateness, it is possible to reduce the expenditure associated with antibiotic prescriptions to outpatient children in the Lombardy region by about one-fifth. The lower rate of hospital admissions for ARI suggests that the adopted profile is also beneficial to children's health.

PMID: 23611435 [PubMed - as supplied by publisher]

Evidence-Based Breast Cancer Screening Guidelines for Women Who Received Chest Irradiation at a Young Age.

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J Clin Oncol. 2013 Apr 22;

Authors: Yahalom J

Abstract

PMID: 23610108 [PubMed - as supplied by publisher]

EFSUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography.Part 2: Clinical Applications.

Related Articles

Ultraschall Med. 2013 Apr 19;

Authors: Cosgrove D, Piscaglia F, Bamber J, Bojunga J, Correas JM, Gilja OH, Klauser AS, Sporea I, Calliada F, Cantisani V, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Fromageau J, Havre RF, Jenssen C, Ohlinger R, Săftoiu A, Schaefer F, Dietrich CF

Abstract
The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.

PMID: 23605169 [PubMed - as supplied by publisher]

Best practice guidelines on clinical management of acute attacks of porphyria and their complications.

Ann Clin Biochem. 2013 Apr 19;

Authors: Stein P, Badminton M, Barth J, Rees D, Stewart MF

Abstract
The British and Irish Porphyria Network guidelines describe best practice in the clinical assessment, investigation and management of acute porphyria attacks and their complications, including severe attacks with neuropathy. Acute attacks of porphyria may occur in acute intermittent porphyria (AIP), variegate porphyria (VP) and hereditary coproporphyria (HCP). Aminolaevulinic acid dehydratase deficiency porphyria (ADP) is a very rare autosomal recessive porphyria; only six cases substantiated by mutation analysis have yet been described in the literature.Urinary porphobilinogen (PBG) is always raised in an acute attack due to AIP, VP or HCP and this analysis is essential to confirm the diagnosis. A positive result in a qualitative or semi-quantitative screening test must be followed by PBG quantitation at the earliest opportunity. However in a severely ill patient, treatment should not be delayed.Removal of precipitating factors, effective analgesia and control of symptoms with safe medication, attention to nutrition and fluid balance are essential. The indications for use of intravenous haem arginate are set out, together with advice on its administration. A small proportion of acute porphyria patients develop recurrent attacks and management options that may be considered include gonadotrophin-releasing hormone analogues, 'prophylactic' regular haem arginate infusion or ultimately, liver transplantation.

PMID: 23605132 [PubMed - as supplied by publisher]

The German evidence-based guidelines for Hodgkin's lymphoma : Aspects for radiation oncologists.

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Strahlenther Onkol. 2013 Apr 21;

Authors: Eich HT, Kriz J, Schmidberger H, Böll B, Klimm B, Rancea M, Müller RP, Engert A

Abstract
This report reviews aspects of the German evidence-based guidelines for Hodgkin's lymphoma relevant to radiation oncologists. Stage-adapted treatment is discussed with the focus on radiotherapy. Up-to-date literature citations provide an overview of current recommendations.

PMID: 23604187 [PubMed - as supplied by publisher]

Impact of the 2005 resuscitation guidelines on patient survival after out-of-hospital cardiac arrest: Experience from a 20-year registry in a middle-eastern country.

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Resuscitation. 2013 Apr 17;

Authors: Salam AM, Albinali HA, Singh R, Al Suwaidi J

PMID: 23603457 [PubMed - as supplied by publisher]

International guidelines for management of metastatic breast cancer (MBC) from the European School of Oncology (ESO)-MBC Task Force: Surveillance, staging, and evaluation of patients with early-stage and metastatic breast cancer.

Related Articles

Breast. 2013 Apr 16;

Authors: Lin NU, Thomssen C, Cardoso F, Cameron D, Cufer T, Fallowfield L, Francis PA, Kyriakides S, Pagani O, Senkus E, Costa A, Winer EP, ESO-MBC Task Force

Abstract
In clinical practice, the surveillance and follow-up of patients with breast cancer (BC) is quite variable. At the 7th European Breast Cancer Conference, the ESO-MBC Task Force convened a series of lectures, followed by open debate, on the use of physical examination, imaging, and laboratory tests in patients with early-stage BC, and for restaging evaluations and follow-up among patients with MBC. Based on the available data, the Task Force recommends against intensive, routine radiologic or blood-based surveillance (with the exception of mammography) in patients with early-stage BC. As systemic therapies for MBC continue to improve, this question might be re-visited in the context of a carefully controlled clinical trial in specific BC subtypes. For patients with MBC, response to therapy should generally be assessed 2-3 months after initiation of treatment, and thereafter every 2-4 months for endocrine therapy or every 2-4 cycles for chemotherapy, depending on the dynamics of the disease, the location and extent of metastatic involvement, and type of treatment. Additional testing should be performed irrespective of the planned intervals if progression of disease is suspected (e.g. in the case of specific symptoms). Use of tumor markers is not recommended for surveillance of early-stage patients, but may be helpful in monitoring response to therapy in patients with metastatic disease. However, change in tumor markers alone should not be used for decision-making. Moving forward, enhanced efforts to document quality of life over time should be made in order to more fully evaluate the risk/benefit ratio of available options.

PMID: 23601761 [PubMed - as supplied by publisher]

Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease.

J Crohns Colitis. 2013 Apr 17;

Authors: Walsh AJ, Weltman M, Burger D, Vivekanandarajah S, Connor S, Howlett M, Radford-Smith G, Selby W, Veillard AS, Grimm MC, Travis SP, Lawrance IC

Abstract
INTRODUCTION: Opportunistic infections are a key safety concern in the management of patients with inflammatory bowel disease (IBD). Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination. The aim of this study was to modify clinical behaviour by use of a simple screening tool. METHODS: A screening and vaccination proforma for hepatitis B, varicella, Influenza, Pneumococcus, human papillomavirus, tuberculosis, hepatitis C and HIV was provided to each participating gastroenterologist. Gastroenterologists were surveyed for awareness of vaccine recommendations and current practice prior to and following the introduction of the proforma. Rates of immunity and the proportion of patients receiving the recommended screening and vaccinations were documented. RESULTS: 30 gastroenterologists at 8 different IBD centres took part in the assessment. A total of 919 patients were included (55% female, 65% Crohn's, 33% ulcerative colitis, 2% indeterminate IBD). Introduction of the proforma increased self-reported gastroenterologist screening from 47% to 97% pre- and post-intervention respectively, p<0.001. After the proforma was applied, vaccination against hepatitis B, varicella, Influenza, and Pneumococcus was recommended in 67%, 2.5%, 75% and 69% of the patients respectively. Of these, 42%, 39%, 66% and 49% patients followed the recommendations and were vaccinated. Cervical smears were recommended in 31%, with 62% of these obtaining the recommended cervical smear. CONCLUSIONS: Implementation of a screening and vaccination proforma significantly changed gastroenterologist self-reported behaviour. Patient compliance with these recommendations was not optimal and suggests the need for further patient education, in addition to other forms of support.

PMID: 23601754 [PubMed - as supplied by publisher]

Evaluation of ICSH schistocyte measurement guidelines in France.

Int J Lab Hematol. 2013 Apr 22;

Authors: Lesesve JF, El Adssi H, Watine J, Oosterhuis W, Régnier F

Abstract
INTRODUCTION: The schistocytes are fragmented red blood cells mainly observed in the setting of hemolytic anemias where they remain an important criterion for the diagnosis. As the identification of these cells is still problematic, the International Council for Standardization in Hematology (ICSH) set up a consensus report in November, 2011. The French Group of Cellular Hematology (GFHC) aimed to collect the opinion of French biologists directly confronted to schistocytes measurements, about these guidelines. METHODS: Among the 578 professionals, 169 (29%) answered to the 10 questions dealing with the identification and measurements of schistocytes as proposed by the ICSH. RESULTS: A consensus was reached for the urgent need of such guidelines documents, especially in the current background of the European accreditation EN ISO 15189 rules. A traduction in native (French) language was warmly wished in order to facilitate the diffusion of the information. The pathologic threshold for the diagnosis of thrombotic microangiopathic anemia (TMA) (>1%) remained questionable. For half of the biologists, the new fragmented red blood cell (FRC) parameter recently provided by two manufacturers of automated blood cell counters was still doubtfull for routine use. CONCLUSION: This survey assessed the impact of international 'guidelines' on the French biological community. The will to implement validated recommendations was strong, reflecting the awareness of the biologists to standardize the laboratory investigations.

PMID: 23601189 [PubMed - as supplied by publisher]

Assessing the economic impact of Rx-to-OTC switches: systematic review and guidelines for future development.

Related Articles

J Med Econ. 2013 Apr 18;

Authors: Cohen J, Millier A, Karray S, Toumi M

Abstract
Abstract Introduction: Switching drugs from prescription to non-prescription status (Rx-to-OTC) presents a unique set of challenges and opportunities to policy-makers and the industry in terms of managing health outcomes, pharmaceutical spending, and steering of consumer choices of therapy. Decision-analytic models are used to address uncertainty and produce reasonable estimates of the economic impact of switches for payers. This article presents a critical literature review of existing models which assess the economic impact of Rx-to-OTC switches, and provides guidelines in which future economic evaluations of Rx-to-OTC switches could be improved. Methods: A comprehensive search strategy was implemented in Medline and Embase, to retrieve published economic evaluations on Rx-to-OTC switches from 1995-2010. The research digest of the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) was reviewed for potentially relevant abstracts for the past 3 years. Each model used was critically evaluated in terms of structure, relevance of inputs, methodology used, and robustness of results. Results: Worldwide, the economic impact of Rx-to-OTC switches has only been evaluated in a total of 12 peer-reviewed publications. Ten out of 12 studies were US-based, and two European-based. The models covered various disease categories, including allergy, hypercholesterolemia, gastroenterology, contraception, pulmonology, and virology. Seventy-five per cent of the models predicted cost savings for payers and patients. Limitations of the models mainly included use of strong assumptions and non-inclusion of specific populations due to lack of data. Guidelines were developed to help future model development. They cover structural issues on decision context, health states, and clinical outcomes, and other considerations for model specifications. Conclusions: Although reviewed studies lacked quality, this review of economic evidence of Rx-to-OTC switches suggests that switches may produce cost savings to public and private payers. This is especially important in light of the trend towards more switches.

PMID: 23597040 [PubMed - as supplied by publisher]

Adherence to a femoral neck fracture treatment guideline.

Related Articles

Int Orthop. 2013 Apr 18;

Authors: Zielinski SM, Meeuwis MA, Heetveld MJ, Verhofstad MH, Roukema GR, Patka P, Van Lieshout EM, On behalf of the Dutch femoral neck fracture investigator group

Abstract
PURPOSE: In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups. METHODS: All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively. RESULTS: From a total of 1,250 patients 59 % had been treated with arthroplasty, 39 % with internal fixation, and 2 % with a non-operative treatment. While 74 % of the treatment choices complied with the guideline, 12 % did not. In 14 % adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2-58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9). CONCLUSIONS: Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.

PMID: 23595233 [PubMed - as supplied by publisher]

Using Evidence to Improve Care: Commentary on an article by Lawson A.B. Copley, MD, MBA, et al.: "The Impact of Evidence-Based Clinical Practice Guidelines Applied by a Multidisciplinary Team for the Care of Children with Osteomyelitis".

Related Articles

J Bone Joint Surg Am. 2013 Apr 17;95(8):e541-2

Authors: Wright JG

PMID: 23595080 [PubMed - in process]

The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis.

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J Bone Joint Surg Am. 2013 Apr 17;95(8):686-93

Authors: Copley LA, Kinsler MA, Gheen T, Shar A, Sun D, Browne R

Abstract
BACKGROUND: Care of children with osteomyelitis requires multidisciplinary collaboration. This study evaluates the impact of evidence-based guidelines for the treatment of pediatric osteomyelitis when utilized by a multidisciplinary team.
METHODS: Guidelines for pediatric osteomyelitis were developed and were implemented by a multidisciplinary team comprised of individuals from several hospital services, including orthopaedics, pediatrics, infectious disease, nursing, and social work, who met daily to conduct rounds and make treatment decisions. With use of retrospective review and statistical analysis, we compared children with osteomyelitis who had been managed at our institution from 2002 to 2004 (prior to the implementation of the guidelines), referred to as Group I in this study, with those who were managed in 2009 according to the guidelines, referred to as Group II.
RESULTS: Two hundred and ten children in Group I were compared with sixty-one children in Group II. No significant differences between the two cohorts were noted for age, sex, incidence of methicillin-resistant Staphylococcus aureus infection (18.1% in Group I compared with 26.2% in Group II), incidence of methicillin-sensitive Staphylococcus aureus infection (23.8% in Group I compared with 27.9% in Group II), bacteremia, or surgical procedures. Significant differences (p &lt; 0.05) between cohorts were noted for each of the following: the delay in magnetic resonance imaging after admission (2.5 days in Group I compared with one day in Group II), the percentage of patients who had received clindamycin as the initial antibiotic (12.9% in Group I compared with 85.2% in Group II), the percentage of patients who had had a blood culture before antibiotic administration (79.5% in Group I compared with 91.8% in Group II), the percentage of patients who had had a culture of tissue from the infection site (62.9% in Group I compared with 78.7% in Group II), the percentage of patients in whom the infecting organism was identified on tissue or blood culture (60.0% in Group I compared with 73.8% in Group II), the number of antibiotic changes (2.0 changes in Group I compared with 1.4 changes in Group II), and the mean duration of oral antibiotic use (27.7 days in Group I compared with 43.7 days in Group II). When compared with Group I, Group II had clinically important trends of a shorter total length of hospital stay (12.8 days in Group I compared with 9.7 days in Group II; p = 0.054) and a lower hospital readmission rate (11.4% in Group I compared with 6.6% in Group II; p = 0.34).
CONCLUSIONS: Evidence-based treatment guidelines applied by a multidisciplinary team resulted in a more efficient diagnostic workup, a higher rate of identifying the causative organism, and improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment. Additionally, there were trends toward lower hospital readmission rates and a shorter length of hospitalization.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID: 23595066 [PubMed - in process]

[Implementation of the German S3-Guideline of non-invasive ventilation for acute respiratory failure in daily practice].

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Dtsch Med Wochenschr. 2013 Apr;138(16):825-30

Authors: Westhoff M

Abstract
Background and objective: Application of non-invasive ventilation (NIV) in acute respiratory failure (ARF) since publication of the German S3 guideline in 2008.Methods: A questionnaire was sent to 145 regional hospitals representing 99 ICUs, asking for: responsibility for NIV, number of ICU-beds, awareness of the guideline and the detailed recommendations, its implementation, use of ventilators and interfaces, location of NIV application.Results: The response rate in relation to hospitals was 43.5 %, 63 questionnaires were sent back (30 by internists, 33 by anesthesiologists). 97 % of the participants reported to know the guideline; 20 (67 %) of the internists and 16 (48,5 %) of the anaesthesiologists who answered are aware of the detailed recommendations. 40 of 63 departments (63,5 %) reported an increase of NIV since publication of the guideline. 22 of 33 (66 %) anaesthesiologists and 18 of 30 (60 %) internists reported to apply NIV in all forms of ARF. The others reported a differentiated application, mainly in pulmonary edema and hypercapnic respiratory failure, whereas NIV was rarely used in non-cardiac hypoxemic ARF. 92 % of the participants used the guideline in decision-finding for NIV. Their decision was additionally influenced by clinical experience. In all clinics NIV took place on the ICU; furthermore in 6 medical clinics on specialized respiratory units. Mainly ICU-ventilators with NIV mode were used; 38 % of the ICUs only held this type of ventilator. In 84 % full-face masks were preferred; 71 % of the users only used a single type of mask.Conclusion: The S3 guideline for NIV in ARF is well-known in intensive care in Germany, but not all are aware of the detailed re-commendations. The use of NIV in ARF has increased since publication of the guideline but nearly always follows additional clinical assessment in decision-making. In one third it is restricted to special indications, with very limited application in non-cardiac hypoxemic ARF. Full-face masks are preferred according to the guideline. All ICUs, that participated in the survey, hold ventilators for NIV.

PMID: 23589044 [PubMed - in process]

Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement.

Nephrol Dial Transplant. 2013 Apr 12;

Authors: Locatelli F, Bárány P, Covic A, De Francisco A, Del Vecchio L, Goldsmith D, Hörl W, London G, Vanholder R, Van Biesen W, on behalf of the ERA-EDTA ERBP Advisory Board

Abstract
Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anaemia in CKD patients. These guidelines addressed all of the important points related to anaemia management in CKD patients, including therapy with erythropoieis stimulating agents (ESA), iron therapy, ESA resistance and blood transfusion use. Because most guidelines were 'soft' rather than 'strong', and because global guidelines need to be adapted and implemented into the regional context where they are used, on behalf of the European Renal Best Practice Advisory Board some of its members, and other external experts in this field, who were not participants in the KDIGO guidelines group, were invited to participate in this anaemia working group to examine and comment on the KDIGO documents in this position paper. In this article, the group concentrated only on those guidelines which we considered worth amending or adapting. All guidelines not specifically mentioned are fully endorsed.

PMID: 23585588 [PubMed - as supplied by publisher]

The influence of time pressure on adherence to guidelines in primary care: an experimental study.

Related Articles

BMJ Open. 2013;3(4)

Authors: Tsiga E, Panagopoulou E, Sevdalis N, Montgomery A, Benos A

Abstract
OBJECTIVES: Evidence from cognitive sciences has systematically shown that time pressure influences decision-making processes. However, very few studies have examined the role of time pressure on adherence to guidelines in clinical practice. The aim of this study was to examine the influence of time pressure on adherence to guidelines in primary care concerning: history taking, clinical examination and advice giving.
DESIGN: A within-subjects experimental design was used.
SETTING: Academic.
PARTICIPANTS: 34 general practitioners (GPs) were assigned to two experimental conditions (time pressure vs no time pressure) consecutively, and presented with two scenarios involving virus respiratory tract infections. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures included adherence to guidelines on history taking, clinical examination and advice giving.
RESULTS: Under time pressure, GPs asked significantly less questions concerning presenting symptoms, than the ones indicated by the guidelines, (p=0.019), conducted a less-thorough clinical examination (p=0.028), while they gave less advice on lifestyle (p=0.05).
CONCLUSIONS: As time pressure increases as a result of high workload, there is a need to examine how adherence to guidelines is affected to safeguard patient's safety.

PMID: 23585394 [PubMed]

Imaging techniques for assessment of inflammatory bowel disease: Joint ECCO and ESGAR evidence-based consensus guidelines.

J Crohns Colitis. 2013 Apr 10;

Authors: Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek J, Weishaupt D, Wiarda B, Laghi A

Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic technique for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

PMID: 23583097 [PubMed - as supplied by publisher]

KHA-CARI Guideline: Recipient Assessment for Transplantation.

Nephrology (Carlton). 2013 Apr 15;

Authors: Campbell S, Pilmore H, Gracey D, Mulley W, Russell C, McTaggart S

PMID: 23581832 [PubMed - as supplied by publisher]

A survey on knowledge of female genital mutilation guidelines.

Related Articles

Acta Obstet Gynecol Scand. 2013 Apr 13;

Authors: Purchase TC, Lamoudi M, Colman S, Allen S, Latthe P, Jolly K

Abstract
The increase in immigration from countries with a high prevalence of female genital mutilation (FGM) has highlighted the need for knowledge and sensitivity in this area of healthcare in high-resource countries. We have surveyed with an online questionnaire 607 members, fellows and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG) on knowledge about the RCOG guidelines for FGM. Completed training and more practical experience with women affected by FGM significantly increased knowledge. Many respondents were not aware of specialist services locally (22.9%) or how to access them (52.3%). Some areas of insufficient knowledge were identified, in particular in relation to psychiatric morbidity, HIV, hepatitis B and pelvic infection. More specialised training efforts might improve this aspect. This article is protected by copyright. All rights reserved.

PMID: 23581719 [PubMed - as supplied by publisher]

Assessing Chronic Pain Treatment Practices and Evaluating Adherence to Chronic Pain Clinical Guidelines in Outpatient Practices in the United States.

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J Pain. 2013 Apr 8;

Authors: Rasu RS, Sohraby R, Cunningham L, Knell ME

Abstract
Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities used in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. The study population of 690,205,290 comprised 63% females, with 45.17% of patient visits occurring in primary care settings. Treatment with at least 1 chronic pain medication was reported in 99.7% of patients. Nonsteroidal anti-inflammatory agents were the most common treatment prescribed, with use reported in approximately 95% of the patient visits. No other pain medication drug class or nonmedication therapy was prescribed more than 26.4%. These results point to a potential underutilization of many recommended NMCP treatments including combination therapies and the need for enhanced education of chronic pain guidelines. PERSPECTIVE: This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.

PMID: 23578958 [PubMed - as supplied by publisher]

Venous thromboprophylaxis duration and adherence to international guidelines in patients undergoing major orthopaedic surgery: Results of the international, longitudinal, observational DEIMOS registry.

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Thromb Res. 2013 Apr 8;

Authors: Arcelus JI, Felicissimo P, on behalf of the DEIMOS Investigators

Abstract
BACKGROUND: Venous thromboembolism (VTE) is major health problem worldwide with substantial morbidity and mortality. This study aimed to assess post-operative VTE prophylaxis duration and adherence to the American College of Chest Physicians (ACCP) 2008 guidelines in patients having undergone major orthopaedic surgery (MOS). METHODS: This multinational, longitudinal, observational registry recruited consecutive patients (≥18years of age) who underwent total hip replacement (THR), total knee replacement (TKR), and hip fracture surgery (HFS). There were 3 study visits: at admission to hospital, at discharge, and 4/6weeks after surgery. Data on demographics, medical history, VTE risk factors, type and duration of mechanical and pharmacological prophylaxis, complications, and adherence to the ACCP 2008 guidelines were collected using case report forms. RESULTS: Between October 2009 and July 2011, 2162 eligible patients were analyzed: THR: 646, TKR: 740, HFS: 776 (mean age [SD]: 64.5 [15.0] years; female: 61.3%; and mean hospitalization duration [SD]: 9.1 [8.2] days). VTE prophylaxis was prescribed to 96.2% of patients during hospitalization and 89.7% of patients after hospital discharge. Prophylaxis was prescribed according to the ACCP 2008 guidelines in 85.7% of patients during hospitalization and 63.4% of patients after hospital discharge. The main reasons for non-adherence to guidelines were no prescription and inadequate duration of prophylaxis. The low molecular weight heparin-enoxaparin-was the most commonly prescribed prophylaxis. CONCLUSION: We observed a gap between real life VTE prophylaxis and the ACCP 2008 recommendations. Improved prescription of extended thromboprophylaxis is warranted to ensure adherence to international guidelines.

PMID: 23578359 [PubMed - as supplied by publisher]

Racial disparities in prostate cancer care: Is adherence to National Comprehensive Cancer Network guidelines good enough for our patients?

Related Articles

Cancer. 2013 Apr 10;

Authors: Master VA, Moses KA

PMID: 23575802 [PubMed - as supplied by publisher]

Receipt of National Comprehensive Cancer Network guideline-concordant prostate cancer care among African American and Caucasian American men in North Carolina.

Related Articles

Cancer. 2013 Apr 10;

Authors: Ellis SD, Blackard B, Carpenter WR, Mishel M, Chen RC, Godley PA, Mohler JL, Bensen JT

Abstract
BACKGROUND: African Americans have a higher incidence of prostate cancer and experience poorer outcomes compared with Caucasian Americans. Racial differences in care are well documented; however, few studies have characterized patients based on their prostate cancer risk category, which is required to differentiate appropriate from inappropriate guideline application. METHODS: The medical records of a population-based sample of 777 North Carolina men with newly diagnosed prostate cancer were studied to assess the association among patient race, clinical factors, and National Comprehensive Cancer Network (NCCN) guideline-concordant prostate cancer care. RESULTS: African Americans presented with significantly higher Gleason scores (P = .025) and prostate-specific antigen levels (P = .008) than did Caucasian Americans. However, when clinical T stage was considered as well, difference in overall risk category only approached statistical significance (P = .055). Across risk categories, African Americans were less likely to have surgery (58.1% versus 68.0%, P = .004) and more likely to have radiation (39.0% versus 27.4%, P = .001) compared with Caucasian Americans. However, 83.5% of men received guideline-concordant care within 1 year of diagnosis, which did not differ by race in multivariable analysis (odds ratio = 0.83; 95% confidence interval  = 0.54-1.25). Greater patient-perceived access to care was associated with greater odds of receiving guideline-concordant care (odds ratio = 1.06; 95% confidence interval = 1.01-1.12). CONCLUSIONS: After controlling for NCCN risk category, there were no racial differences in receipt of guideline-concordant care. Efforts to improve prostate cancer treatment outcomes should focus on improving access to the health care system. Cancer 2013;000:000-000. © 2013 American Cancer Society.

PMID: 23575751 [PubMed - as supplied by publisher]

In-hospital cardiac arrests: effect of amended Australian Resuscitation Council 2006 guidelines.

Aust Health Rev. 2013 Apr;37(2):178-84

Authors: Boyde MS, Padget M, Burmeister E, Aitken LM

Abstract
Objective To evaluate cardiac arrest outcomes following the introduction of the Australian Resuscitation Council (ARC) 2006 amended guidelines for basic and advanced life support. Methods A retrospective study of all consecutive cardiac arrests during a 3-year phase pre-implementation (2004-06) and a 3-year phase post-implementation (2007-09) of the ARC 2006 guidelines was conducted at a tertiary referral hospital in Brisbane, Australia. Results Over the 6-year study phase 690 cardiac arrests were reported. Resuscitation was attempted in 248 patients pre-implementation and 271 patients post-implementation of the ARC 2006 guidelines. After adjusting for significant prognostic factors we found no significant change in return of spontaneous circulation (ROSC) (odds ratio 1.21, 95% confidence interval 0.80-1.85, P=0.37) or survival to discharge (odds ratio 1.49, 95% confidence interval 0.94-2.37, P=0.09) after the implementation of the ARC 2006 guidelines. Factors that remained significant in the final model for both outcomes included having an initial shockable rhythm, a shorter length of time from collapse to arrival of cardiac arrest team, location of the patient in a critical-care area, shorter length of resuscitation and a day-time arrest (0700-2259hours). In addition the arrest being witnessed was significant for ROSC and younger age was significant for survival to discharge. Conclusions There are multiple factors that influence clinical outcomes following an in-hospital cardiac arrest and further research to refine these significant variables will assist in the future management of cardiac arrests. What is known about this topic? The evaluation of outcomes from in-hospital cardiac arrests focuses on immediate survival expressed as ROSC and survival to hospital discharge. These clinical outcomes have not improved substantially over the last two decades. What does this paper add? This paper identifies the factors that are related to ROSC and survival to discharge following the implementation of the ARC 2006 guidelines, which included a refocus on providing quality cardiopulmonary resuscitation with minimal interruptions. What are the implications for practitioners? Given that multiple factors can influence clinical outcomes following an in-hospital cardiac arrest, focusing on maximising a range of factors surrounding cardiopulmonary resuscitation is essential to improve outcomes.

PMID: 23575506 [PubMed - in process]

[Assessment of Hungarian ESA and G-CSF treatments to national and international guidelines and protocols].

Magy Onkol. 2013 Apr;57(1):50-5

Authors: Nagy Z

Abstract
Chemotherapy induced neutropenia (CIN), febrile neutropenia (FN), chemotherapy induced anemia (CIA) frequently occur following myelosuppressive chemotherapy and are associated with morbidity, mortality, costs, and relative dose intensity (RDI), hence influencing overall survival (OS). Given prophylactically, granulocyte colony-stimulating factors (G-CSFs) can stimulate neutrophil production and depletion, they may thus reduce FN incidence when following chemotherapy. Erythropoietins are widely used to treat chemotherapy induced anemia. Several guidelines have been published to help onco-hematologists design their supportive therapy. The aim of our study was to assess the guidelines concerning everyday routine in supportive care. The final conclusion is that the Hungarian therapy support guidelines are up to date, are highly compliant with international standards [ASCO (1), EORTC (2), ESMO (3, 4), NCCN (5-7)], and that the clinicians have a deep understanding and comprehensive usage in their everyday practice.

PMID: 23573522 [PubMed - in process]

Guidelines for secondary analysis in search of response shift.

Related Articles

Qual Life Res. 2013 Apr 10;

Authors: Schwartz CE, Ahmed S, Sawatzky R, Sajobi T, Mayo N, Finkelstein J, Lix L, Verdam MG, Oort FJ, Sprangers MA

Abstract
OBJECTIVE: Response shift methods have developed substantially in the past decade, with a notable emphasis on model-based methods for response shift detection that are appropriate for the analysis of existing data sets. These secondary data analyses have yielded useful insights and motivated the continued growth of response shift methods. However, there are also challenges inherent to the successful use of secondary analysis for response shift detection. Based on our experience with a number of secondary analyses, we propose guidelines for the optimal implementation of secondary analysis for detecting response shift. METHODS: We review the definition of response shift and recent advances in response shift theory. We describe current statistical methods that have been developed for or applied to response shift detection. We then discuss lessons learned when using these methods to test specific hypotheses about response shift in existing data and of the features of a data set that could guide early decision-making about undertaking a secondary analysis. RESULTS: A checklist is provided that includes guidelines for secondary analyses focusing on: (1) selecting an appropriate data set to investigate response shift; (2) prerequisites of data sets and their preparation for analysis; (3) managing missing data; (4) confirming that the data fit the requirements and assumptions of the selected response shift detection technique; (5) model fit evaluation; (6) interpreting results/response shift effect sizes; and (7) comparing findings across methods. CONCLUSIONS: The guidelines-checklist has the potential to stimulate rigorous and replicable research using existing data sets and to assist investigators in assessing the appropriateness and potential of a data set and model-based methods for response shift research.

PMID: 23572398 [PubMed - as supplied by publisher]

Implementation of guidelines for implantable cardioverter-defibrillator therapy in clinical practice: Which patients do benefit?

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Neth Heart J. 2013 Apr 10;

Authors: Wijers SC, van der Kolk BY, Tuinenburg AE, Doevendans PA, Vos MA, Meine M

Abstract
PURPOSE: Based on multiple large clinical trials conducted over the last decades guidelines for implantable cardioverter-defibrillator (ICD) implantations have been evolving. The increase in primary prophylactic ICD implantations challenges us to be critical towards the indications in certain patient populations. METHODS: We retrospectively collected patient characteristics and rates of appropriate and inappropriate ICD therapy, appropriate and inappropriate ICD shock and mortality of all patients who received an ICD in the University Medical Center Utrecht (UMCU) over the years 2006-2011. RESULTS: A total of 1075 patients were included in this analysis (74 % male, mean age 61 ± 13 years, left ventricular ejection fraction 30 ± 13 %); 61 % had a primary indication and 58 % had ischaemic heart disease. During a mean follow-up period of 31 ± 17 months, 227 of the patients (21 %) received appropriate ICD therapy (149 (14 %) patients received an appropriate ICD shock). Females, patients with a primary prophylactic indication and patients with non-ischaemic heart disease experienced significantly less ICD therapy. Only a few patients (54, 5 %) received inappropriate ICD therapy; 33 (3 %) patients received an inappropriate ICD shock. Fifty-five patients died within one year after ICD implantation and were therefore, in retrospect, not eligible for ICD implantation. CONCLUSION: Our study confirms the benefit of ICD implantation in clinical practice. Nevertheless, certain patients experience less benefit than others. A more patient-tailored risk stratification based on electrophysiological parameters would be lucrative to improve clinical benefit and cost-effectiveness.

PMID: 23572330 [PubMed - as supplied by publisher]

GRADE guidelines 15: Going from evidence to recommendation-determinants of a recommendation's direction and strength.

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J Clin Epidemiol. 2013 Apr 6;

Authors: Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, Elbarbary M, Post P, Nasser M, Shukla V, Jaeschke R, Brozek J, Djulbegovic B, Guyatt G

Abstract
In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. This article addresses GRADE's approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention.

PMID: 23570745 [PubMed - as supplied by publisher]

Evidence-based guideline: Treatment of parenchymal neurocysticercosis: Report of the Guideline Development Subcommittee of the American Academy of Neurology.

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Neurology. 2013 Apr 9;80(15):1424-1429

Authors: Baird RA, Wiebe S, Zunt JR, Halperin JJ, Gronseth G, Roos KL

Abstract
OBJECTIVE: To review the evidence base for different treatment strategies in intraparenchymal neurocysticercosis in adults and children. METHOD: A literature search of Medline, EMBASE, LILACS, and the Cochrane Database from 1980 to 2008, updated in 2012, resulted in the identification of 10 Class I or Class II trials of cysticidal drugs administered with or without corticosteroids in the treatment of neurocysticercosis. RESULTS: The available data demonstrate that albendazole therapy, administered with or without corticosteroids, is probably effective in decreasing both long-term seizure frequency and the number of cysts demonstrable radiologically in adults and children with neurocysticercosis, and is well-tolerated. There is insufficient information to assess the efficacy of praziquantel. RECOMMENDATIONS: Albendazole plus either dexamethasone or prednisolone should be considered for adults and children with neurocysticercosis, both to decrease the number of active lesions on brain imaging studies (Level B) and to reduce long-term seizure frequency (Level B). The evidence is insufficient to support or refute the use of steroid treatment alone in patients with intraparenchymal neurocysticercosis (Level U).

PMID: 23568997 [PubMed - as supplied by publisher]

Validation of the Hong Kong Accident and Emergency Triage Guidelines.

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Hong Kong Med J. 2013 Apr 3;

Authors: Fan MM, Leung LP

Abstract
OBJECTIVE. To validate the Hong Kong Accident and Emergency Triage guidelines. DESIGN. Retrospective chart review. SETTING. The Accident and Emergency Department of a tertiary hospital in Hong Kong. PARTICIPANTS. Patients who attended the Accident and Emergency Department on one day in February 2012. MAIN OUTCOME MEASURES. The inter-rater reliability in two pairs of nurses grouped according to experience and validity as compared with an expert panel. RESULTS. Of the 100 patients recruited and triaged into levels 1 to 5, the weighted kappa coefficient (inter-rater reliability) for the two pairs of nurses was 0.699 and 0.717, respectively. The weighted kappa coefficient for validity was 0.766. When only patients in triage levels 3 and 4 were included, the weighted kappa coefficient for reliability dropped to 0.632 and 0.585, respectively. The weighted kappa coefficient for validity also decreased to 0.558. CONCLUSIONS. The overall inter-rater reliability and validity of the Guidelines appeared acceptable. Further revision of the Guidelines on triaging patients to levels 3 or 4 is probably necessary.

PMID: 23568939 [PubMed - as supplied by publisher]

Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia - A survey study.

Related Articles

Intensive Crit Care Nurs. 2013 Apr 5;

Authors: Jansson M, Ala-Kokko T, Ylipalosaari P, Syrjälä H, Kyngäs H

Abstract
OBJECTIVES: To explore critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. DESIGN: A quantitative cross-sectional survey. METHODS: Two multiple-choice questionnaires were distributed to critical care nurses (n=101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses' knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. RESULTS: The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p=0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance. CONCLUSION: There is an ongoing need for improvements in education and effective implementation strategies. CLINICAL IMPLICATIONS: The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control.

PMID: 23566622 [PubMed - as supplied by publisher]

Malpractice and medical liability. European Guidelines on Methods of Ascertainment and Criteria of Evaluation.

Related Articles

Int J Legal Med. 2013 May;127(3):545-57

Authors: Ferrara SD, Baccino E, Bajanowski T, Boscolo-Berto R, Castellano M, De Angel R, Pauliukevičius A, Ricci P, Vanezis P, Vieira DN, Viel G, Villanueva E, EALM Working Group on Medical Malpractice

Abstract
The manuscript presents the European Guidelines on medico-legal Methods of Ascertainment and Criteria of Evaluation in cases of suspected subjective "Medical Responsibility and/or Liability" developed by an international working group under the patronage of the European Academy of Legal Medicine. It includes a step-by-step illustrated explanation of approved Flow Charts, articulated in 18 sequential steps and comprehensive of both Methods of Ascertainment and Evaluation Criteria.

PMID: 23564275 [PubMed - in process]

The impact of the Japanese clinical guidelines on the clinical management of patients with acute cholecystitis.

Related Articles

J Hepatobiliary Pancreat Sci. 2013 Apr 9;

Authors: Shinya S, Yamashita Y, Takada T

Abstract
BACKGROUND/PURPOSE: The Japanese clinical guidelines for treating acute cholecystitis (AC), proposed in 2005, provide criteria not only for diagnosis, but also for management depending on the severity of the disease. The aim of this study was to assess how the Japanese guidelines for AC have impacted the clinical situation in Japan. METHODS: A postal questionnaire was sent to the councillors of the Japanese Society of Abdominal Emergency Medicine three times to ascertain the impact of the Japanese guidelines for AC. We surveyed 291 councillors one year before publication of the guidelines (2004), 279 councillors one year after publication (2006), and 191 councillors six years after publication (2011). RESULTS: The response rate was 72.5 % one year before publication of the guidelines, 51.9 % one year later and 69.1 % six years after publication. Early cholecystectomy was used by 41.7 % of the respondents one year before publication, while 57.3 % of the respondents used this treatment one year after publication and 62.3 % of the respondents used it six years after publication. Laparoscopic cholecystectomy was used by 79.1 % of the respondents one year before the guidelines were published, while 87.3 % of the respondents used it one year after publication and 90 % of the respondents reported its use six years after publication. CONCLUSIONS: The Japanese guidelines for AC are increasingly used and have changed the clinical management of patients with AC. The use of early and laparoscopic cholecystectomy for treating patients with AC has been increasingly adopted in Japan.

PMID: 23564194 [PubMed - as supplied by publisher]

[International guidelines of the Surviving Sepsis Campaign : Update 2012].

Related Articles

Anaesthesist. 2013 Apr;62(4):304-9

Authors: Briegel J, Möhnle P

Abstract
An update of the international guidelines for therapy of sepsis was published in February 2012 by the Surviving Sepsis Campaign (SSC). The update includes a further development of the guidelines from 2004 and 2008. The guidelines are divided into three sections, sepsis-specific therapeutic measures, recommendations on general intensive care measures for sepsis and finally special features of sepsis in pediatric intensive care medicine are presented in detail. This article discusses the most important amendments in the first two sections and delving deeper into the guidelines.

PMID: 23558718 [PubMed - in process]

HbA1c targets in type 2 diabetes: guidelines and evidence.

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Drug Ther Bull. 2013 Apr;51(4):42-5

Authors:

Abstract
Type 2 diabetes is defined by chronic hyperglycaemia, decreased insulin secretion and increased insulin resistance and is often associated with overweight or obesity, hypertension and dyslipidaemia.(1) Aims of treatment include minimising long-term complications (e.g. cardiovascular disease, blindness, chronic kidney disease, premature mortality) and avoiding unwanted effects of treatment (e.g. severe hypoglycaemia, weight gain).(1) Publication of the United Kingdom Prospective Diabetes Study (UKPDS) 33 study in 1998 suggested that 'intensive blood glucose control' to lower the glycated haemoglobin (HbA1c) in people with type 2 diabetes reduced microvascular disease but not macrovascular complications.(2) The UKPDS 34 study in overweight patients found that metformin produced less of a reduction in HbA1c but reduced cardiovascular complications and death.(3) More recently, further trials have examined the impact of intensive glycaemic control and have produced conflicting results.(1,4-11) Here we examine the evidence and guideline recommendations for HbA1c targets; glycaemic control for acutely unwell patients and targets in pregnancy will not be covered.

PMID: 23557845 [PubMed - in process]

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study.

Related Articles

BMC Fam Pract. 2013;14:47

Authors: Fürthauer J, Flamm M, Sönnichsen A

Abstract
BACKGROUND: Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients' side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician's as well as the patient's view.
METHODS: With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.
RESULTS: Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient's non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.
CONCLUSIONS: Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians' lack of knowledge and patients' lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

PMID: 23557543 [PubMed - in process]

Adherence to the World Cancer Research Fund/American Institute for Cancer Research guidelines and risk of death in Europe: results from the European Prospective Investigation into Nutrition and Cancer cohort study1,4.

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Am J Clin Nutr. 2013 May;97(5):1107-20

Authors: Vergnaud AC, Romaguera D, Peeters PH, van Gils CH, Chan DS, Romieu I, Freisling H, Ferrari P, Clavel-Chapelon F, Fagherazzi G, Dartois L, Li K, Tikk K, Bergmann MM, Boeing H, Tjønneland A, Olsen A, Overvad K, Dahm CC, Redondo ML, Agudo A, Sánchez MJ, Amiano P, Chirlaque MD, Ardanaz E, Khaw KT, Wareham NJ, Crowe F, Trichopoulou A, Orfanos P, Trichopoulos D, Masala G, Sieri S, Tumino R, Vineis P, Panico S, Bueno-de-Mesquita HB, Ros MM, May A, Wirfält E, Sonestedt E, Johansson I, Hallmans G, Lund E, Weiderpass E, Parr CL, Riboli E, Norat T

Abstract
BACKGROUND: In 2007, the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) issued recommendations on diet, physical activity, and weight management for cancer prevention on the basis of the most comprehensive collection of available evidence.
OBJECTIVE: We investigated whether concordance with WCRF/AICR recommendations is related to risk of death.
DESIGN: The current study included 378,864 participants from 9 European countries enrolled in the European Prospective Investigation into Cancer and Nutrition study. At recruitment (1992-1998), dietary, anthropometric, and lifestyle information was collected. A WCRF/AICR score, which incorporated 6 of the WCRF/AICR recommendations for men [regarding body fatness, physical activity, foods and drinks that promote weight gain, plant foods, animal foods, and alcoholic drinks (score range: 0-6)] and 7 WCRF/AICR recommendations for women [plus breastfeeding (score range: 0-7)], was constructed. Higher scores indicated greater concordance with WCRF/AICR recommendations. Associations between the WCRF/AICR score and risks of total and cause-specific death were estimated by using Cox regression analysis.
RESULTS: After a median follow-up time of 12.8 y, 23,828 deaths were identified. Participants within the highest category of the WCRF/AICR score (5-6 points in men; 6-7 points in women) had a 34% lower hazard of death (95% CI: 0.59, 0.75) compared with participants within the lowest category of the WCRF/AICR score (0-2 points in men; 0-3 points in women). Significant inverse associations were observed in all countries. The WCRF/AICR score was also significantly associated with a lower hazard of dying from cancer, circulatory disease, and respiratory disease.
CONCLUSION: Results of this study suggest that following WCRF/AICR recommendations could significantly increase longevity.

PMID: 23553166 [PubMed - in process]

[Emergency room management : In the era of the White Paper, S3 guidelines, Advanced Trauma Life Support® and TraumaNetwork DGU® of the German Society of Trauma Surgery.]

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Chirurg. 2013 Apr 5;

Authors: Krueger A, Frink M, Kiessling A, Ruchholtz S, Kühne CA

Abstract
The treatment of the severely injured is, just as the injury severity and combinations, often highly complex and leaves little leeway for delay, dissent or even error. In order to reduce this to a minimum, trained emergency room teams in addition to optimal technical and structural prerequisites are necessary. This must function in an interdisciplinary fashion according to fixed consensus algorithms which are known to all team members and have been agreed by all participants. The White Paper on treatment of the severely injured of the German Society of Trauma Surgery (DGU) and the recently published S3 guidelines offer evidence-based recommendations on the structural, technical, organizational and personnel prerequisites.

PMID: 23553150 [PubMed - as supplied by publisher]

National guidelines for high-cost drugs in Brazil: achievements and constraints of an innovative national evidence-based public health policy.

Int J Technol Assess Health Care. 2013 Apr;29(2):198-206

Authors: Picon PD, Beltrame A, Banta D

Abstract
Introduction: The translation of best evidence into practice has become an important purpose of policy making in health care. In Brazil, a country of continental dimensions with widespread regional and social inequalities, the dissemination and use of the best-evidence in policy making is a critical issue for the healthcare system. Objectives: The main purpose of this study is to describe an evidence-based public health policy with special emphasis on guidelines creation for high-cost medicines. We also describe how that strategy was diffused to the judiciary system and to other parts of the healthcare system. Results: We present an 11-year follow-up of a national project for creating and updating guidelines for high-cost medicines in Brazil. A total of 109 national guidelines were published (new or updated versions) for 66 selected diseases, the first such effort in Brazilian history. The project influenced the Brazilian legislature, which has recently established a Federal Law requiring national guidelines for any new technology listed for payment by the Brazilian public healthcare system. Conclusion: We were able to involve many different stakeholders in a partnership between academia and policy makers, which made possible the widespread dissemination of the clinical practice guidelines. Problems and constraints were also encountered. This evolving public health strategy might be useful for other developing countries.

PMID: 23552016 [PubMed - in process]

Does an enhanced recovery integrated care pathway (ICP) encourage adherence to prescribing guidelines, accelerate postoperative recovery and reduce the length of stay for gynaecological oncology patients?

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J Obstet Gynaecol. 2013 Apr;33(3):296-7

Authors: Letton C, Cheung C, Nordin A

Abstract
A new integrated care pathway (ICP) proforma for gynaecological oncology patients was developed and introduced in early 2010. The ICP is a goal-defined and time-specified documentation by gynaecological oncology doctors and nurses, guided by certain parameters to be achieved in pre and postoperative days. All patients were admitted to the same unit and underwent a major abdominal/pelvic procedure for confirmed or suspected gynaecological malignancy, including hysterectomy and oophorectomy. The control group included 58 randomly selected patients from May 2008 to March 2009 and the intervention group comprised 52 patients, after the introduction of the ICP. The effectiveness was assessed with a variety of measurements: the duration of intraperitoneal drains, urethral catheters and intravenous fluids postoperatively; time taken for the patient to eat and drink; time taken to mobilisation; and the total length of stay in hospital. We also assessed whether the implementation of the care pathway was associated with an increase in adherence to prescribing guidelines for thromboprophylaxis and postoperative antibiotics and sodium docusate. The new ICP encouraged clearer documentation and regular review of fluids, drains and catheters. There was a modest reduction in the length of stay and an increase in prescribed thromboprophylaxis and sodium docusate ( Cheung et al. 2011 ).

PMID: 23550863 [PubMed - in process]

Systematic review: the quality of the scientific evidence and conflicts of interest in international inflammatory bowel disease practice guidelines.

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Aliment Pharmacol Ther. 2013 May;37(10):937-46

Authors: Feuerstein JD, Akbari M, Gifford AE, Cullen G, Leffler DA, Sheth SG, Cheifetz AS

Abstract
BACKGROUND: Guidelines published by the international gastroenterology societies establish standards of care and seek to improve patient outcomes.
AIM: We examined inflammatory bowel disease guidelines (IBD) for quality of evidence, methods of grading evidence and conflicts of interest (COI).
METHODS: All 182 guidelines published by the American College of Gastroenterology, American Gastroenterological Association, British Society of Gastroenterology, Canadian Association of Gastroenterology, Crohn's and Colitis Foundation of America and European Crohn's and Colitis Organisation as of 27 September 2012 were reviewed. Nineteen IBD guidelines were found.
RESULTS: Eighty-nine per cent (n = 17/19) of the guidelines graded the levels of evidence using seven different systems. Of the 1070 recommendations reviewed, 23% (n = 249) cited level A evidence; 28% (n = 302) level B; 36% (n = 383) level C and 13% (n = 136) level D. The mean age of the guidelines was 4.2 years. In addition, 61% (n = 11/19) of the guidelines failed to comment on COI. All eight articles commenting on COI had conflicts with 81% (n = 92/113) of authors reported an average 11.7 COI. Lastly, there were variations in the recommendations between societies.
CONCLUSIONS: Nearly half the IBD guideline recommendations are based on expert opinion or no evidence. Majority of the guidelines fail to disclose any COI, and when commenting, all have numerous COI. Furthermore, the guidelines are not updated frequently and there is a lack of consensus between societal guidelines. This study highlights the critical need to centralize and redesign the guidelines development process.

PMID: 23550536 [PubMed - in process]

Benchmarking CIN 3+ risk as the basis for incorporating HPV and Pap cotesting into cervical screening and management guidelines.

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J Low Genit Tract Dis. 2013 Apr;17(5 Suppl 1):S28-35

Authors: Katki HA, Schiffman M, Castle PE, Fetterman B, Poitras NE, Lorey T, Cheung LC, Raine-Bennett T, Gage JC, Kinney WK

Abstract
OBJECTIVE: In 2012, the US Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and human papillomavirus (HPV) testing ("cotesting") for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN 3+).
METHODS: We estimated cumulative 5-year risks of CIN 3+ for 965,360 women aged 30 to 64 years undergoing cotesting at Kaiser Permanente Northern California over 2003 to 2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/atypical squamous cells of undetermined significance (ASC-US) and HPV-negative/Pap-negative. We call this guidance process "benchmarking."
RESULTS: A low-grade squamous intraepithelial lesion result, for which immediate colposcopy is prescribed, carries a 5-year CIN 3+ risk of 5.2%, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6% risk) is managed with a 6- to 12-month follow-up visit and Pap-negative (0.26% risk) is managed with a 3-year follow-up visit. The 5-year CIN 3+ risk for women with HPV-positive/ASC-US was 6.8% (95% confidence interval = 6.2%-7.6%). This is greater than the 5.2% risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN 3+ risk for women with HPV-negative/Pap-negative was 0.08% (95% confidence interval = 0.07%-0.09%), far below the 0.26% implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return.
CONCLUSIONS: Using the principle of "equal management of equal risks," benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting.

PMID: 23519302 [PubMed - in process]

American College of Chest Physicians Guidelines for Heparin-Induced Thrombocytopenia: A Need for Evidence-Based Assessment of the Baseline Risk of Heparin-induced Thrombocytopenia.

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Chest. 2013 Apr 1;143(4):1190-1

Authors: Junqueira DR

PMID: 23546508 [PubMed - in process]

Quality of reporting and evidence in american academy of pediatrics guidelines.

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Pediatrics. 2013 Apr;131(4):732-8

Authors: Isaac A, Saginur M, Hartling L, Robinson JL

Abstract
OBJECTIVES: The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations.
METHODS: Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines.
RESULTS: For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05).
CONCLUSIONS: There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.

PMID: 23530180 [PubMed - in process]

AAP clinical guidelines: ongoing process improvements.

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Pediatrics. 2013 Apr;131(4):794-5

Authors: Woods CR

PMID: 23530165 [PubMed - in process]

Prevention and Treatment of Venous Thromboembolism: International Consensus Statement (Guidelines according to scientific evidence).

Clin Appl Thromb Hemost. 2013 Apr;19(2):116-8

Authors: Nicolaides A, Hull RD, Fareed J

PMID: 23529476 [PubMed - in process]

Adherence to guidelines for diabetes care in school: family and school nurse perspectives.

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Diabetes Care. 2013 Apr;36(4):e52

Authors: Macleish SA, Cuttler L, Koontz MB

PMID: 23520378 [PubMed - in process]

The AGA institute process for developing clinical practice guidelines part one: grading the evidence.

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Clin Gastroenterol Hepatol. 2013 Apr;11(4):329-32

Authors: Sultan S, Falck-Ytter Y, Inadomi JM

PMID: 23517554 [PubMed - in process]

Fish micronucleus assay to assess genotoxic potential of arsenic at its guideline exposure in aquatic environment.

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Biometals. 2013 Apr;26(2):337-46

Authors: Kumar A, Kesari VP, Khan PK

Abstract
The exposure to arsenic, a potential genotoxic carcinogen in humans, via drinking water is a serious worldwide health hazard. The arsenic content of 10 μg L(-1) in drinking water, however, has been established as its guideline standard (maximum contaminant limit) that has been estimated to pose minimum risk to cancer. Since micronucleus induction in the erythrocytes of fish is a sensitive indicator of genotoxic agents in water, the piscine micronucleus assay was used in the present experiment to assess the genotoxic potential of arsenic at its various exposure levels including the guideline value for drinking water. The experiments were conducted in two different species of fishes, the pond murrel (Channa punctatus) and the goldfish (Carassius auratus). Significant increases in the frequency of micronucleated erythrocytes were documented in a dose-dependent manner in both Channa and Carassius. The fishes, however, exhibited variations in inter-specific sensitivity to micronucleus induction following arsenic exposure. The exposure level of arsenic at its guideline value for drinking water, therefore, exhibited marked genotoxicity in fishes.

PMID: 23494554 [PubMed - in process]

Multisociety consensus quality improvement guidelines for intra-arterial catheter-directed treatment of acute ischemic stroke: implications for neuroradiology and stroke centers.

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AJNR Am J Neuroradiol. 2013 Apr;34(4):697-9

Authors: Connors JJ, Black CM

PMID: 23493887 [PubMed - in process]

Counterpoint: Randomized trials provide the strongest evidence for clinical guidelines: The US Preventive Services Task Force and Prostate Cancer Screening.

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Med Care. 2013 Apr;51(4):301-3

Authors: Melnikow J, LeFevre M, Wilt TJ, Moyer VA

Abstract
BACKGROUND: The US Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening for prostate cancer based primarily on 2 large long-term randomized-controlled trials (RCTs) and a systematic review of harms resulting from screening.
OBJECTIVE: To support use of large, long-term randomized trials as the evidence base for clinical guidelines on screening and to draw attention to limitations of modeling studies used for this purpose.
METHODS: We respond to critiques of use of RCTs as the primary evidence base, considering the results of the Prostate, Lung, Colorectal and Ovarian (PLCO) and European Randomized Study of Screening for Prostate Cancer (ERSPC) trials, documented harms resulting from PSA screening, and methodological concerns with modeling studies.
RESULTS: The PLCO and ERSPC provided 11-13 years of follow-up on over 250,000 subjects. The PLCO, despite limitations, is most representative of US populations, screening and treatment practices, and showed no mortality benefit resulting from annual PSA testing after 13 years of follow-up. The confidence interval was narrow and precluded more than a 13% relative mortality reduction. Competing causes of mortality in older men make it progressively less likely that longer follow-up will demonstrate a large absolute reduction in disease-specific mortality. With continued screening, the increasing prevalence of asymptomatic cancers in older men will increase the rate of overdiagnosis. Potential harms from screening and treatment are significant.
CONCLUSIONS: Projections from models are subject to mistaken assumptions and investigator biases, and should not be accorded the same weight as evidence from RCTs. Current empiric evidence is sufficient to support the US Preventive Services Task Force guideline that clinicians should recommend against PSA screening for prostate cancer.

PMID: 23481031 [PubMed - in process]

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder.

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World J Biol Psychiatry. 2013 Apr;14(3):154-219

Authors: Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Möller HJ, Kasper S, WFSBP Task Force on Treatment Guidelines for Bipolar Disorders

Abstract
OBJECTIVES: These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults.
METHODS: Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned.
RESULTS: Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios.
CONCLUSIONS: Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

PMID: 23480132 [PubMed - in process]

[Pancreatic cancer in the elderly : Guidelines and individualized therapy].

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Chirurg. 2013 Apr;84(4):291-5

Authors: Nieß H, Kleespies A, Andrassy J, Pratschke P, Angele MK, Guba M, Jauch KW, Bruns CJ

Abstract
The considerable increase of the aged population in western civilisation within the next years will result in a rising incidence of pancreatic cancer. Until the year 2020 an increment of 20  % of patients beyond 65 years old can be anticipated. Therefore, the focus will be on management of old and geriatric surgical patients leading to strategical re-evaluation of surgical indications under critical consideration of feasibility and purpose. Even under modern interdisciplinary therapy concepts the prognosis of ductal adenocarcinoma of the pancreas remains poor with an overall 5-year survival rate of less than 5  %. The surgical resection is still considered as the only potential curative treatment option with extended life expectancy; however, it is technically demanding and furthermore associated with significant morbidity. In particular, the quality of surgery of the now interdisciplinary therapy of pancreatic cancer is markedly improved when performed at a high-volume centres. Until now only a few retrospective data analyses evaluating the perioperative and long-term outcome after pancreatic tumor resections in geriatric patients exist. The available results, however, support radical surgical procedures even beyond the age of 75 years.

PMID: 23479275 [PubMed - in process]

[Treatment of gastric cancer beyond current guideline : State of the art].

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Chirurg. 2013 Apr;84(4):310-5

Authors: Schuhmacher C, Novotny A, Meyer HJ

Abstract
The majority of recommendations in the current S3 guideline on the diagnosis and treatment of gastric carcinoma are based on good clinical practice and lack supporting randomized studies. With the development of endoscopic resection and multimodal treatment concepts, pretherapeutic tumor staging has gained in importance. However, the accuracy of present imaging modalities is still limited with a tendency towards overstaging of locally advanced tumors. Extended lymph node dissection cannot be recommended in cases with advanced lymph node involvement. In cardiac cancer retroperitoneal lymphatic spread to the left renal vein is an early event and should thus not be classified as stage IV disease. In cases of intra-abdominal gastrectomy a pouch reconstruction should be considered in cases with a good overall prognosis. Subgroup analyses indicate a differential therapeutic effect of the established perioperative chemotherapy depending on the location of the primary tumor. There is also good evidence for an additional beneficial effect of radiotherapy in combination with chemotherapy.

PMID: 23479274 [PubMed - in process]

Improving adherence to otitis media guidelines with clinical decision support and physician feedback.

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Pediatrics. 2013 Apr;131(4):e1071-81

Authors: Forrest CB, Fiks AG, Bailey LC, Localio R, Grundmeier RW, Richards T, Karavite DJ, Elden L, Alessandrini EA

Abstract
OBJECTIVE: To assess the effects of electronic health record-based clinical decision support (CDS) and physician performance feedback on adherence to guidelines for acute otitis media (AOM) and otitis media with effusion (OME).
METHODS: We conducted a factorial-design cluster randomized trial with primary care practices (n = 24) as the unit of randomization and visits as the unit of analysis. Between December 2007 and September 2010, data were collected from 139 305 otitis media visits made by 55 779 children aged 2 months to 12 years. When activated, the CDS system provided guideline-based recommendations individualized to the patient's history and presentation. Monthly physician feedback reported adherence to guideline-based care, changes over time, and comparisons to others in the practice and network.
RESULTS: Comprehensive care (all recommended guidelines were adhered to) was accomplished for 15% of AOM and 5% of OME visits during the baseline period. The increase from baseline to intervention periods in adherence to guidelines was larger for CDS compared with non-CDS visits for comprehensive care, pain treatment, adequate diagnostic evaluation for OME, and amoxicillin as first-line therapy for AOM. Although performance feedback was associated with improved antibiotic prescribing for AOM and pain treatment, the joint effects of CDS and feedback on guideline adherence were not additive. There was marked variation in use of the CDS system, ranging from 5% to 45% visits across practices.
CONCLUSIONS: Clinical decision support and performance feedback are both effective strategies for improving adherence to otitis media guidelines. However, combining the 2 interventions is no better than either delivered alone.

PMID: 23478860 [PubMed - in process]

Adherence to the WCRF/AICR Guidelines for Cancer Prevention is Associated with Lower Mortality Among Older Female Cancer Survivors.

Cancer Epidemiol Biomarkers Prev. 2013 Apr 10;

Authors: Inoue-Choi M, Robien K, Lazovich D

Abstract
BACKGROUND: The 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) guidelines encourage cancer survivors to follow its cancer prevention recommendations. We evaluated whether adherence to the WCRF/AICR guidelines for cancer prevention was associated with lower mortality among older female cancer survivors.METHODS: From 2004 to 2009, 2,017 participants in the Iowa Women's Health Study who had a confirmed cancer diagnosis (1986-2002) and completed the 2004 follow-up questionnaire were followed. Adherence scores for the WCRF/AICR guidelines for body weight, physical activity, and diet were computed assigning one, 0.5 or 0 points to each of eight recommendations depending on the degree of adherence. All-cause (n = 461), cancer-specific (n = 184), and cardiovascular disease (CVD)-specific mortality (n = 145) were compared by the total adherence score and by adherence scores for each of the three components of the recommendations.RESULTS: Women with the highest (6-8) versus lowest (0-4) adherence score had lower all-cause mortality [HR = 0.67; 95% confidence of interval (CI), 0.50-0.94]. Meeting the physical activity recommendation was associated with lower all-cause (Ptrend < 0.0001), cancer-specific (Ptrend = 0.04), and CVD-specific mortality (Ptrend = 0.03). Adherence to dietary recommendations was associated with lower all-cause mortality (Ptrend < 0.05), whereas adherence to the body weight recommendation was associated with higher all-cause mortality (Ptrend = 0.009).CONCLUSIONS: Adherence to the WCRF/AICR guidelines was associated with lower all-cause mortality among older female cancer survivors. Adherence to the physical activity recommendation had the strongest association with lower all-cause and disease-specific mortality.Impact: Older cancer survivors may decrease their risk of death by leading a healthy lifestyle after a cancer diagnosis. Cancer Epidemiol Biomarkers Prev; 1-11. ©2013 AACR.

PMID: 23462914 [PubMed - as supplied by publisher]

Deviations from guideline-based therapy for febrile neutropenia in cancer patients and their effect on outcomes.

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JAMA Intern Med. 2013 Apr 8;173(7):559-68

Authors: Wright JD, Neugut AI, Ananth CV, Lewin SN, Wilde ET, Lu YS, Herzog TJ, Hershman DL

Abstract
IMPORTANCE Although febrile neutropenia (FN) is a major source of morbidity and mortality for patients with solid tumors, little is known about the use of guideline-based care. OBJECTIVES To examine compliance with guideline-based recommendations for FN treatment, explore the factors that influence adherence to consensus guidelines, and analyze how the use of guideline-based care affects the outcomes. DESIGN The Perspective database was used to examine the treatment of cancer patients with FN from January 1, 2000, through March 31, 2010. To capture initial decision making, we examined treatment within 48 hours of hospital admission. We determined use of guideline-based antibiotics and nonguideline-based treatments, vancomycin, and granulocyte colony-stimulating factors (GCSF). Hierarchical models were developed to examine the factors associated with treatment. Patients were stratified into low- and high-risk groups, and the effect of the initial treatment on outcome (nonroutine hospital discharge and death) was examined. SETTING AND PARTICIPANTS Twenty-five thousand two hundred thirty-one patients with solid tumors hospitalized for neutropenia. MAIN OUTCOME MEASURE Use of guideline-based antibiotics, vancomycin, and GCSF and their affect on outcome. RESULTS Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high FN-volume hospitals (odds ratio [OR], 1.56; 95% CI, 1.34-1.81) by high FN-volume physicians (OR, 1.19; 95% CI, 1.03-1.38) and patients managed by hospitalists (OR, 1.49; 95% CI, 1.18-1.88) were more likely to receive guideline-based antibiotics (P &lt; .05). Vancomycin use increased from 17% in 2000 to 55% in 2010, while GCSF use only decreased from 73% to 55%. Among low-risk patients with FN, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility (OR, 0.77; 95% CI, 0.65-0.92) and death (OR, 0.63; 95% CI, 0.42-0.95). CONCLUSIONS AND RELEVANCE While use of guideline-based antibiotics is high, use of the nonguideline-based treatments, vancomycin, and GCSF is also high. Physician and hospital factors are the strongest predictors of both guideline- and nonguideline-based treatment.

PMID: 23460379 [PubMed - in process]

Guideline-Adherent Care vs Quality Care in Cancer Patients: Twins or Distant Cousins?Comment on "Deviations From Guideline-Based Therapy for Febrile Neutropenia in Cancer Patients and Their Effect on Outcomes".

Related Articles

JAMA Intern Med. 2013 Apr 8;173(7):569-70

Authors: Chen RC

PMID: 23460294 [PubMed - in process]

POLYPOIDAL CHOROIDAL VASCULOPATHY: Evidence-Based Guidelines for Clinical Diagnosis and Treatment.

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Retina. 2013 Apr;33(4):686-716

Authors: Koh AH, Chen LJ, Chen SJ, Chen Y, Giridhar A, Iida T, Kim H, Yuk Yau Lai T, Lee WK, Li X, Han Lim T, Ruamviboonsuk P, Sharma T, Tang S, Yuzawa M, on behalf of the Expert PCV Panel

Abstract
BACKGROUND:: Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy affecting vision, with clinical features distinct from neovascular age-related macular degeneration. Currently, no evidence-based guidelines exist for its diagnosis and treatment. METHODS:: A panel of experts analyzed a systematic literature search on PCV together with results of the EVEREST trial, the only published randomized controlled clinical trial in PCV. At a subsequent Roundtable meeting, recommendations for the management of PCV were agreed based on this analysis and their own expert opinion. RESULTS:: Diagnosis of PCV should be based on early-phase nodular hyperfluorescence from choroidal vasculature visualized using indocyanine green angiography. Recommended initial treatment of juxtafoveal and subfoveal PCV is either indocyanine green angiography-guided verteporfin photodynamic therapy or verteporfin photodynamic therapy plus 3 × 0.5 mg ranibizumab intravitreal injections 1 month apart. If there is incomplete regression of polyps by indocyanine green angiography, eyes should be retreated with verteporfin photodynamic therapy monotherapy or verteporfin photodynamic therapy plus ranibizumab. If there is complete regression of polyps by indocyanine green angiography, but there is leakage on fluorescein angiography and other clinical or anatomical signs of disease activity, eyes should be retreated with ranibizumab. CONCLUSION:: Practical guidance on the clinical management of PCV is proposed based on expert evaluation of current evidence.

PMID: 23455233 [PubMed - as supplied by publisher]

European Association of Urology Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence.

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Actas Urol Esp. 2013 Apr;37(4):199-213

Authors: Lucas MG, Bosch RJ, Burkhard FC, Cruz F, Madden TB, Nambiar AK, Neisius A, de Ridder DJ, Tubaro A, Turner WH, Pickard RS

Abstract
CONTEXT: The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology. OBJECTIVE: We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination. EVIDENCE ACQUISITION: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system. EVIDENCE SUMMARY: The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice. CONCLUSIONS: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

PMID: 23452548 [PubMed - as supplied by publisher]

Weight loss interventions in asthma: EAACI evidence-based clinical practice guideline (part I).

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Allergy. 2013 Apr;68(4):425-39

Authors: Moreira A, Bonini M, Garcia-Larsen V, Bonini S, Del Giacco SR, Agache I, Fonseca J, Papadopoulos NG, Carlsen KH, Delgado L, Haahtela T

Abstract
BACKGROUND: Asthma and obesity are chronic multifactorial conditions that are associated with gene-environment interaction and immune function. Although the data are not fully consistent, it seems that obesity increases the risk of asthma and compromises asthma control.
OBJECTIVE: To investigate the impact that weight changes have on asthma.
METHODS: We carried out a systematic review of three large biomedical databases. Studies were scrutinized and critically appraised according to agreed exclusion and inclusion criteria. Quality assessment of eligible papers was conducted using the GRADE method. Meta-analyses of comparable studies were carried out.
RESULTS: Thirty studies met the eligibility criteria of the review. Interventions were limited to dietary manipulation in three studies, one of which also used anti-obesity drugs, and bariatric surgery in four. All the other studies reported observational data. Becoming obese increased the odds for incident asthma by 1.82 (95% CI 1.47, 2.25) in adults and 1.98 (95% CI 0.71, 5.52) in children. Weight loss was associated with significant improvement in mean scores for symptoms, rescue medication score, and asthma exacerbations in the only randomized controlled trial. Similarly, evidence gathered from observational studies, with follow-up ranging between 8 weeks to 1 year, and from changes 1 year after bariatric surgery showed improvements in all asthma control-related outcomes. Changes in lung function were reported in one randomized controlled and eight observational studies of asthmatic subjects, with conflicting results. Either improvement after weight loss, decline with weight gain, or no effects at all were reported. Changes in airway inflammation and responsiveness were reported only by observational studies.
CONCLUSION: Weight increases above the obesity threshold significantly increase the risk of asthma. The available studies show weak evidence of benefits from weight reduction on asthma outcomes.

PMID: 23452010 [PubMed - in process]

Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care.

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Eur J Anaesthesiol. 2013 Apr;30(4):142-62

Authors: Bonhomme F, Ajzenberg N, Schved JF, Molliex S, Samama CM, French Anaesthetic and Intensive Care Committee on Evaluation of Routine Preoperative Testing

Abstract
Recently the French Society of Anaesthesia and Intensive Care (Société Française d'Anesthésie et de Réanimation [SFAR]) issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia. Thirty clinical specialists performed a systematic analysis of the literature, and recommendations were then developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. One part of these guidelines is dedicated to haemostatic assessment. The goal of pre-anaesthetic screening for congenital or acquired haemostatic disorders is to prevent perioperative haemorrhagic complications through appropriate medical and surgical management. Preoperative assessment of bleeding risk requires a detailed patient interview to determine any personal or family history of haemorrhagic diathesis, and a physical examination is necessary in order to detect signs of coagulopathy. Laboratory investigation of haemostasis should be prescribed, not systematically, but depending on clinical evaluation and patient history. Standard tests (prothrombin time, activated partial thromboplastin time, platelet count) have a low positive predictive value for bleeding risk in the general population. Patients with no history of haemorrhagic diathesis and no conditions liable to interfere with haemostasis should not undergo pre-interventional haemostasis testing. Conversely, the existence of a positive history or a disease that could interfere with haemostasis should be an indication for clinically appropriate testing.

PMID: 23435255 [PubMed - in process]

Adherence to NICE guidelines for new glaucoma referrals.

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Eye (Lond). 2013 Apr;27(4):571-2

Authors: Chaudhary R, Dhillion N, Jones L

PMID: 23429410 [PubMed - in process]

Clinical pharmacogenetics implementation consortium guidelines for thiopurine methyltransferase genotype and thiopurine dosing: 2013 update.

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Clin Pharmacol Ther. 2013 Apr;93(4):324-5

Authors: Relling MV, Gardner EE, Sandborn WJ, Schmiegelow K, Pui CH, Yee SW, Stein CM, Carrillo M, Evans WE, Hicks JK, Schwab M, Klein TE

PMID: 23422873 [PubMed - in process]

Evidence-based guideline recommendations on the use of positron emission tomography imaging in head and neck cancer from Ontario and guidelines in general--some observations.

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Clin Oncol (R Coll Radiol). 2013 Apr;25(4):242-5

Authors: Wong WL, Ross P, Corcoran M

PMID: 23422786 [PubMed - in process]

Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines.

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J Acad Nutr Diet. 2013 Apr;113(4):520-45

Authors: Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, Frearson M, Thondan M, Stepto N, Teede HJ

Abstract
While lifestyle management is recommended as first-line treatment of polycystic ovary syndrome (PCOS), the optimal dietary composition is unclear. The aim of this study was to compare the effect of different diet compositions on anthropometric, reproductive, metabolic, and psychological outcomes in PCOS. A literature search was conducted (Australasian Medical Index, CINAHL, EMBASE, Medline, PsycInfo, and EBM reviews; most recent search was performed January 19, 2012). Inclusion criteria were women with PCOS not taking anti-obesity medications and all weight-loss or maintenance diets comparing different dietary compositions. Studies were assessed for risk of bias. A total of 4,154 articles were retrieved and six articles from five studies met the a priori selection criteria, with 137 women included. A meta-analysis was not performed due to clinical heterogeneity for factors including participants, dietary intervention composition, duration, and outcomes. There were subtle differences between diets, with greater weight loss for a monounsaturated fat-enriched diet; improved menstrual regularity for a low-glycemic index diet; increased free androgen index for a high-carbohydrate diet; greater reductions in insulin resistance, fibrinogen, total, and high-density lipoprotein cholesterol for a low-carbohydrate or low-glycemic index diet; improved quality of life for a low-glycemic index diet; and improved depression and self-esteem for a high-protein diet. Weight loss improved the presentation of PCOS regardless of dietary composition in the majority of studies. Weight loss should be targeted in all overweight women with PCOS through reducing caloric intake in the setting of adequate nutritional intake and healthy food choices irrespective of diet composition.

PMID: 23420000 [PubMed - in process]

Evidence-based guidelines for anti-allergic drug withdrawal times before allergen-specific intradermal and IgE serological tests in dogs.

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Vet Dermatol. 2013 Apr;24(2):225-e49

Authors: Olivry T, Saridomichelakis M, International Committee on Atopic Diseases of Animals (ICADA)

Abstract
BACKGROUND: Anti-allergic drugs (e.g. antihistamines, glucocorticoids and ciclosporin) are often administered to dogs with atopic dermatitis to relieve pruritus and skin lesions. Allergen-specific intradermal tests (IDT) and allergen-specific IgE serological (ASIS) tests are used to characterize the allergens to which dogs are hypersensitive. Anti-allergic drugs have the potential to influence the results or interpretation of these tests.
OBJECTIVES: To provide evidence-based recommendations for anti-allergic drug withdrawal times before IDT and ASIS tests.
METHODS: Three citation databases and abstracts from international meetings were searched for relevant studies. Studies were grouped based on similar interventions and types of tests. Withdrawal times for each type of drug and test were then extrapolated from the study results.
RESULTS: Before the assessment of immediate reactions to IDT, proposed optimal withdrawal times for antihistamines, oral glucocorticoids, topical/otic glucocorticoids and ciclosporin are 7, 14, 14 and 0 days, respectively. Studies have provided no evidence for drug withdrawal prior to ASIS tests for oral ciclosporin or prednisone/prednisolone. Owing to a lack of studies, recommendations for withdrawal times before ASIS tests cannot be made for topical glucocorticoids and antihistamines.
CONCLUSIONS AND CLINICAL IMPORTANCE: These proposed withdrawal times are based on the existing evidence at the end of 2011. Care must be taken before extrapolating the suggested withdrawal times to other species, higher dosages, different formulations and/or durations of administration of tested drugs, as well as to other medications from the same category.

PMID: 23402664 [PubMed - in process]

Reaching targets for mineral metabolism clinical practice guidelines and its impact on outcomes among mexican chronic dialysis patients.

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Arch Med Res. 2013 Apr;44(3):229-34

Authors: Paniagua R, Ventura MD, Avila-Díaz M, Hinojosa-Heredia H, Méndez-Duran A, Cisneros A, Gómez AM, Cueto-Manzano A, Trinidad P, Obrador GT, García-López E, Lindholm B

Abstract
BACKGROUND AND AIMS: An increasing number of studies have been published concerning meeting targets of clinical guidelines for different aspects of the diagnosis and treatment of patients with end-stage renal disease. Most of these studies have shown that guideline recommendations are not always satisfied, and results outside target limits have been associated with high rates of mortality and morbidity. The objective of this study was to analyze the frequency of reaching mineral and bone metabolism-related guideline targets and its impact on clinical outcomes in Mexican chronic dialysis patients.
METHODS: A cohort of prevalent peritoneal dialysis (PD) and hemodialysis (HD) patients were analyzed at baseline and followed for at least 16 months. Patients were on continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD), and HD and contracted HD modalities where patients received HD sessions outside institution facilities.
RESULTS: We studied 753 patients. The percentage of patients within target limits for phosphorus was 35%, for calcium 32%, and for PTH 12%. The most frequent pattern was hyperphosphatamia, hypercalcemia, and low PTH. This was even more frequent in CAPD patients, probably due to the high percentage of diabetic patients. Hypercalcemia was found as an independent risk factor for mortality.
CONCLUSIONS: The most important results suggest that guideline recommendations are not usually satisfied and that hypercalcemia, in addition to other traditional risk factors, is associated with high mortality rates. The study also detected some opportunities to improve the quality of treatment by reducing the calcium content of dialysis solutions and reducing the use of calcium carbonate as a phosphate binder.

PMID: 23398790 [PubMed - in process]

Triage of children with headache at the ED: a guideline implementation study.

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Am J Emerg Med. 2013 Apr;31(4):670-5

Authors: Balossini V, Zanin A, Alberti C, Freund Y, Decobert M, Tarantino A, La Rocca M, Lacroix L, Spiri D, Lejay E, Armoogum P, Wood C, Gervaix A, Zuccotti GV, Perilongo G, Bona G, Mercier JC, Titomanlio L

Abstract
We present a multicenter validation of a modified Manchester Triage System (MTS) flowchart for pediatric patients who present with headache to the emergency department. A prospective observational study was conducted across 5 European pediatric emergency departments. The standard MTS headache flowchart and a modified MTS headache flowchart were tested in the participating centers, and results were compared with triage categories identified by either the physician at the end of the clinical examination or the reference classification matrix (RCM). Fifty-three patients were enrolled in the preimplementation phase and 112 in the postimplementation phase. When compared with physician's triage and RCM, the modified MTS flowchart demonstrated good sensitivity (79% and 70%, respectively), specificity (77% and 76%, respectively), and a high positive likelihood ratio (9.14 and 16.75, respectively) for the identification of low-risk children. Conclusions: Our modified headache flowchart is safe and reliable in pediatric emergency settings, especially for lower classes of urgency.

PMID: 23380115 [PubMed - in process]

Evaluating Acceptance and User Experience of a Guideline-based Clinical Decision Support System Execution Platform.

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J Med Syst. 2013 Apr;37(2):9910

Authors: Buenestado D, Elorz J, Pérez-Yarza EG, Iruetaguena A, Segundo U, Barrena R, Pikatza JM

Abstract
This study aims to determine what the initial disposition of physicians towards the use of Clinical Decision Support Systems (CDSS) based on Computerised Clinical Guidelines and Protocols (CCGP) is; and whether their prolonged utilisation has a positive effect on their intention to adopt them in the future. For a period of 3 months, 8 volunteer paediatricians monitored each up to 10 asthmatic patients using two CCGPs deployed in thee-GuidesMed CDSS. A Technology Acceptance Model (TAM) questionnaire was supplied to them before and after using the system. Results from both questionnaires are analysed searching for significant improvements in opinion between them. An additional survey was performed to analyse the usability of the system. It was found that initial disposition of physicians towards e-Guidesmed is good. Improvement between the pre and post iterationsof the TAM questionnaire has been found to be statistically significant. Nonetheless, slightly lower values in the Compatibility and Habit variables show that participants perceive possible difficulties to integrate e-GuidesMed into their daily routine. The variable Facilitators shows the highest correlation with the Intention to Use. Usabilityof the system has also been rated very high and, in this regard, no fundamental flaw has been detected. Initial views towards e-GuidesMed are positive, and become reinforced after continued utilisation of the system. In order to achieve an effective implementation, it becomes essential to facilitate conditions to integrate the system intothe physician's daily routine.

PMID: 23377779 [PubMed - in process]

Risk assessment in hypertrophic cardiomyopathy: contemporary guidelines hampered by insufficient evidence.

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Heart. 2013 Apr;99(8):511-3

Authors: McKeown PP, Muir AR

PMID: 23376948 [PubMed - in process]

A medication assessment tool to evaluate adherence to medication guideline in asthmatic children.

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Int J Clin Pharm. 2013 Apr;35(2):289-95

Authors: Liu HP, Chen HY, Johnson J, Lin YM

Abstract
Objective Asthma is one of the commonest causes of morbidity and mortality in childhood. The goals of the present study were to design a valid medication assessment tool for evaluating the quality of medication use according to recommendations of updated asthma guidelines for children aged from 5 to 12 years, and to quantify adherence to guideline recommendations. Setting Two primary care settings in Scotland, UK. Methods Recommendations related to the long-term management of asthmatic children in the British Thoracic Society/Scottish Intercollegiate Guidelines Network and Global Initiative for Asthma guidelines were identified and corresponding criteria were created. These criteria were incorporated to generate an assessment tool named MAT ASTHMA-PAED. Two phases of field-testing were undertaken and the tool was also subject to examination by a focus group of specialist practitioners. Thereafter, MAT ASTHMA-PAED was modified accordingly. Main outcome measure Applicability and adherence to each criterion and overall adherence to the MAT ASTHMA-PAED. Results The MAT ASTHMA-PAED field-testing was undertaken in two primary care practices in Scotland, United Kingdom and 77 asthmatic children were recruited. Results of the pilot study field-testing showed a high overall adherence of 70.0 % (95 % CI: 58.7-81.3 %) to the guidelines. Low adherence (<50 %) was seen for 4 criteria, whereas 8 criteria were considered high-adherence criteria (>70 %). The final MAT ASTHMA-PAED comprised of 25 criteria was produced based on the results of field testing and the opinions from the focus group. Conclusion Although high utility of MAT ASTHMA-PAED criteria was found, there were gaps in the implementation of certain recommendations, particularly in relation to demonstrated satisfactory technique of inhaler. Moreover, further studies assessing the use of oral steroids and exercise-induced asthma, and wider implementation of MAT ASTHMA-PAED are required.

PMID: 23359031 [PubMed - in process]

Use of electronic medical record-based tools to improve compliance with cervical cancer screening guidelines: effect of an educational intervention on physicians' practice patterns.

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J Low Genit Tract Dis. 2013 Apr;17(2):175-81

Authors: White P, Kenton K

Abstract
OBJECTIVE: This study aimed to determine whether electronic medical record (EMR)-based tools influence providers' compliance with guidelines for cervical cancer screening in adolescent (<21 y) patients.
MATERIALS AND METHODS: Three EMR-based tools to educate providers on cervical cancer screening guidelines were implemented midyear in 2010. Charts of adolescents with Pap and/or human papillomavirus results from January to December 2010 were reviewed. Physicians' demographic data were collected. Appropriateness of the index Pap and follow-up were determined using American Society for Colposcopy and Cervical Pathology guidelines.
RESULTS: A total of 380 Pap tests were completed on 374 adolescents. Fewer Pap tests were done after the EMR interventions (229 vs 151, p < .0005). The proportion of Pap tests ordered by primary care providers was significantly higher than obstetrician-gynecologists (Ob/Gyns) (70% vs 30%, p < .0005). The number of Pap tests done by Ob/Gyns decreased 60% after EMR interventions (from 82 to 33, p < .0005) and that done by primary care physicians decreased 20% (from 147 to 118, p = .08). Indicated Pap tests were more often ordered by Ob/Gyn than by primary care, especially after EMR changes (31.4% vs 7.6%, p < .0005). Reflex human papillomavirus testing (if atypical squamous cells of undetermined significance) was high (74%) and did not improve after the EMR changes (72% vs 76%). The rate of co-testing in adolescents decreased in the primary care department after the EMR changes (13% vs 6%, p = .049).
CONCLUSIONS: Electronic medical record prompts improved compliance with cervical cytology guidelines for adolescents, suggesting that EMR may be an important tool to enhance compliance with changing recommendations.

PMID: 23343700 [PubMed - in process]

Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer.

Related Articles

J Hum Nutr Diet. 2013 Apr;26(2):182-90

Authors: Brown T, Findlay M, von Dincklage J, Davidson W, Hill J, Isenring E, Talwar B, Bell K, Kiss N, Kurmis R, Loeliger J, Sandison A, Taylor K, Bauer J

Abstract
BACKGROUND: The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency.
METHODS: A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics.
RESULTS: In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min.
CONCLUSIONS: Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated.

PMID: 23336961 [PubMed - in process]

Korean guidelines for pharmacoeconomic evaluation (second and updated version) : consensus and compromise.

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Pharmacoeconomics. 2013 Apr;31(4):257-67

Authors: Bae S, Lee S, Bae EY, Jang S

Abstract
The first version of the Korean guidelines for pharmacoeconomic evaluation was published by Health Insurance Review and Assessment Service (HIRA) in 2006. Since the introduction of the first version, domestic experience with the application of the recommendations has accumulated, and methodologies in certain areas have progressed considerably. Based on these experiences, HIRA initiated a guidelines revision project to address the need for revisions. The purpose of this study is to share the process used to complete these guideline revisions and to provide the contents of the revised guidelines. In developing the current revision, meetings with the advisory committee and working-level meetings with pharmaceutical companies were held several times to reach as much of a consensus as possible, and the results of a survey of pharmaceutical companies and decision makers regarding the existing guidelines were considered. The second version of the guidelines clarified the level of data requirement ('must', 'recommended', 'preferred') based on the data availability, the information needs of the decision makers and the strength of the evidence. The recommended perspective economic studies should take has been modified and additional guidance has been provided on QALY measurement. Manuals for systematic reviews and indirect comparisons have been published, and a standardized reporting format for expert opinions has been added. Sections on preferred methods for evaluations, sensitivity analysis, modelling and time horizon have been elucidated. The revised guidelines clarify the expression of the recommendations, making them more user-friendly, and provide more specific guidance to improve the quality and comparability across submissions.

PMID: 23322587 [PubMed - in process]

Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer.

Related Articles

Cancer. 2013 Apr 15;119(8):1593-601

Authors: Boland GM, Chang GJ, Haynes AB, Chiang YJ, Chagpar R, Xing Y, Hu CY, Feig BW, You YN, Cormier JN

Abstract
BACKGROUND: The objective of the current study was to examine the impact of adherence to guidelines on stage-specific survival outcomes in patients with stage III and high-risk stage II colon cancer. The National Comprehensive Cancer Network (NCCN) has established working, expert consensus, and evidence-based guidelines for organ-specific cancer care, including care of patients with colon cancer.
METHODS: Patients who were diagnosed with colon adenocarcinoma between 1998 and 2002 were selected from within the National Cancer Data Base. The cohort was limited to patients who received their first course of treatment at the reporting facility. Pathologic variables, including tumor depth, lymph node status, and evidence of metastatic disease, were used to restage patients, and the patients were divided into low-risk and high-risk categories on the basis of criteria defined by the NCCN. Relative survival rates were calculated for the entire cohort, stratified according to adherence versus nonadherence to NCCN treatment guidelines.
RESULTS: In univariate analysis of treatment adherence patterns for both patient subgroups (high-risk stage II and stage III), several factors were associated with a higher rate of nonadherence in both groups, including older age (P < .001); Medicaid, Medicare, or uninsured status versus private insurance (P < .001); and subsequent treatment at a facility other than the facility at which the cancer was first diagnosed (P < .001). In multivariate analysis, multiple factors were associated with differences in relative survival, although analyses that included the year of diagnosis did not demonstrate significant differences over time.
CONCLUSIONS: The current study documented practice patterns in a heterogeneous population of patients with colon cancer and demonstrated a survival benefit for patients with stage III and high-risk stage II colon cancer who received treatment that adhered to NCCN guidelines. These data validate the current NCCN practice guidelines for colon cancer and support the concept of guideline-based metrics that can be compared across institutions to assess the quality of cancer care and to compare the quality of cancer care among institutions. Cancer 2013. © 2012 American Cancer Society.

PMID: 23280510 [PubMed - in process]

Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part 2: Remote extension assessment and exploration for secondary synchronous locations outside of the upper aerodigestive tract. 2012 SFORL guidelines.

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Eur Ann Otorhinolaryngol Head Neck Dis. 2013 Apr;130(2):107-12

Authors: de Monès E, Bertolus C, Salaun PY, Dubrulle F, Ferrié JC, Temam S, Chevalier D, Vergez S, Lagarde F, Schultz P, Lapeyre M, Barry B, Tronche S, de Raucourt D, Morinière S

Abstract
OBJECTIVES: This report presents the French Society of ORL (SFORL) guidelines for exploration for remote metastasis and synchronous second cancer in initial staging of head and neck squamous cell carcinoma.
MATERIALS AND METHODS: An exhaustive literature review was analyzed by a multidisciplinary work-group.
RESULTS: The thorax is the most frequent location of remote metastases and synchronous second cancer outside of the upper aerodigestive tract. Thoracic CT is recommended as first-line examination in all cases (grade B). 18-FDG PET/CT is recommended when the thoracic CT image is doubtful or in case of high metastatic risk (grade B), for the detection of non-pulmonary remote metastasis. Esophageal exploration is recommended in case of significant risk of synchronous esophageal cancer (hypopharyngeal or oropharyngeal tumor, chronic alcohol intoxication) (grade B). The reference examination is flexible endoscopy of the upper digestive tract (grade B).
CONCLUSION: The present grade B recommendations rationalize the roles of the various first-line radiological and endoscopic examinations for remote metastasis and synchronous second cancer, so as to limit the number of examinations performed, thereby reducing the time needed for initial staging.

PMID: 23273886 [PubMed - in process]

Evaluation of adherence to international guidelines for treating patients with type 2 diabetes mellitus in Kuwait.

Related Articles

Int J Clin Pharm. 2013 Apr;35(2):244-50

Authors: Al-Taweel DM, Awad AI, Johnson BJ

Abstract
Background Clinical guidelines derived from scientific evidence provide the basis of consistent standardized prescribing. Despite an alarming increase of diabetes in Kuwait, no studies related to the quality of prescribing in diabetes were found. Before pharmaceutical care can be implemented to improve the quality of care of patients with diabetes, it is important to determine whether prescribers are compliant with comprehensive international guidelines for cardioprevention and glycaemic control. Objective To evaluate the adherence to clinical guidelines for treating patients with type 2 diabetes mellitus in primary care centres and secondary care centres (hospitals) using a developed and validated medication assessment tool with reference to international guidelines. Setting Outpatient diabetes clinics in 8 primary care centres and 4 secondary care centres across four healthcare regions in Kuwait. Method A quantitative, cross-sectional study involving a sample of 652 Kuwaiti patients with type 2 diabetes, who were selected using systematic sampling from the study settings. Data were collected retrospectively from the patients' medical records using a validated 43-criterion medication assessment tool (MATKW) designed to assess cardioprevention and treatment in patients with type 2 diabetes. Descriptive and comparative analysis was conducted using SPSS version 17. Main Outcome Measure Frequency of prescribing adherence to agreed definitions of criteria derived from international guidelines. Results Overall adherence to prescribing diabetes guidelines was 77.7 % (95 % CI 76.7-78.6 %). Significantly higher prescribing adherence was found in the secondary care facilities, 82.4 % (95 % CI 81.2-83.6 %) compared to primary care 72.5 % (95 % CI 71.0-73.9 %) (p < 0.001). Nineteen criteria out of 43 achieved an adherence >80 % in secondary care compared to ten criteria in primary care. The documentation of patients' records was found to be inconsistent at the study healthcare facilities. Nonoptimal achievement of target goals for HbA1c, blood pressure and BMI was prevalent among the study population. Conclusion: A tool such as MATKW highlights areas for review and possible improvement in prescribing adherence. Our findings reveal problem areas in prescribing practices and documentation of patients' records. Cost-effective multifaceted interventions are needed to improve current prescribing practices and documentation.

PMID: 23254942 [PubMed - in process]

Interactions between pre-processing and classification methods for event-related-potential classification : best-practice guidelines for brain-computer interfacing.

Related Articles

Neuroinformatics. 2013 Apr;11(2):175-92

Authors: Farquhar J, Hill NJ

Abstract
Detecting event related potentials (ERPs) from single trials is critical to the operation of many stimulus-driven brain computer interface (BCI) systems. The low strength of the ERP signal compared to the noise (due to artifacts and BCI irrelevant brain processes) makes this a challenging signal detection problem. Previous work has tended to focus on how best to detect a single ERP type (such as the visual oddball response). However, the underlying ERP detection problem is essentially the same regardless of stimulus modality (e.g. visual or tactile), ERP component (e.g. P300 oddball response, or the error-potential), measurement system or electrode layout. To investigate whether a single ERP detection method might work for a wider range of ERP BCIs we compare detection performance over a large corpus of more than 50 ERP BCI datasets whilst systematically varying the electrode montage, spectral filter, spatial filter and classifier training methods. We identify an interesting interaction between spatial whitening and regularised classification which made detection performance independent of the choice of spectral filter low-pass frequency. Our results show that pipeline consisting of spectral filtering, spatial whitening, and regularised classification gives near maximal performance in all cases. Importantly, this pipeline is simple to implement and completely automatic with no expert feature selection or parameter tuning required. Thus, we recommend this combination as a "best-practice" method for ERP detection problems.

PMID: 23250668 [PubMed - in process]

Cost-effectiveness of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

Related Articles

Int J Nurs Stud. 2013 Apr;50(4):518-26

Authors: Huis A, Hulscher M, Adang E, Grol R, van Achterberg T, Schoonhoven L

Abstract
BACKGROUND: Many strategies have been designed and evaluated to address poor hand hygiene compliance. Unfortunately, well-designed economic evaluations of hand hygiene improvement strategies are lacking.
OBJECTIVE: To compare the cost-effectiveness of two successful implementation strategies for improving nurses' hand hygiene compliance and reducing hospital acquired infections (HAI's).
DESIGN AND SETTING: A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands. The evaluation used a hospital perspective.
PARTICIPANTS: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the control group (n=30) or the experimental group (n=37).
METHODS: The control group received a state-of-the-art strategy including education, reminders feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy which included all elements of the state-of-the-art strategy supplemented with interventions aimed at the social context of teams and enhancing leadership. The most efficient implementation strategy was determined by the incremental cost-effectiveness ratio per extra percentage of hand hygiene compliance gained and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio's. Two scenarios of 15 and 30% were used to express the association between increased hand hygiene compliance and the reduction in HAIs.
RESULTS: The team and leaders-directed strategy was significantly more effective in improving hand hygiene compliance. The mean difference effect was 8.91% (95% CI, 0.75-17.06). This extra increase was achieved at an average cost of €5497 per ward. The incremental cost per extra percentage of hand hygiene gained on ward level was €622. The incremental cost per additional percentage reduction in the HAI rate on ward level was €2074 (30% scenario) and €4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the team and leaders-directed strategy is cost-effective and within the 15% scenario, there is a probability of 70% that the team and leaders-directed strategy is cost-effective.
CONCLUSIONS: Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy.

PMID: 23245456 [PubMed - in process]

Adherence to national guidelines for antiemesis prophylaxis in patients undergoing chemotherapy for lung cancer: a population-based study.

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Cancer. 2013 Apr 1;119(7):1428-36

Authors: Gomez DR, Liao KP, Giordano S, Nguyen H, Smith BD, Elting LS

Abstract
BACKGROUND: Nausea and vomiting (N/V) during chemotherapy can have profound clinical and economic consequences. Effective antiemetic agents are available for prophylaxis, but barriers may prevent their use. For this population-based study, the authors assessed the rates of antiemetic prophylaxis use, and predictors of such use, among patients who were receiving platinum-based chemotherapy for lung cancer between 2001 and 2007.
METHODS: The authors searched the Texas Cancer Registry-Medicare-linked database for individuals aged >65 years who received platinum-based chemotherapy within 12 months after a first diagnosis of lung cancer from 2001 to 2007; and all patients had continuous Medicare Part A and Part B coverage for the same period. Adherence to recommended regimens for N/V prophylaxis (established by the National Comprehensive Cancer Network) was scored as a binary variable (adherent vs nonadherent) and was calculated as the percentages of treated patients receiving each recommended agent within 1 day of beginning chemotherapy. Logistic regression with stepwise selection was used to examine whether patient characteristics influenced adherence.
RESULTS: Of 4566 selected patients, adherence rates for the receipt of serotonin antagonists (eg, ondansetron) with dexamethasone were 60% to 90% regardless of whether the chemotherapy agent was considered moderately or highly emetogenic. The receipt of substance-P antagonists was much less common (<10%) during any period. On multivariate logistic regression modeling, variables that predicted adherence were older age, white race, higher median income, and concurrent radiation therapy.
CONCLUSIONS: Recommended use of antiemetics for prophylaxis, especially substance-P antagonists, during chemotherapy for lung cancer is suboptimal. Factors that were correlated with adherence suggest socioeconomic barriers in the community.

PMID: 23212885 [PubMed - in process]

NSGC practice guideline: risk assessment and genetic counseling for hereditary breast and ovarian cancer.

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J Genet Couns. 2013 Apr;22(2):155-63

Authors: Berliner JL, Fay AM, Cummings SA, Burnett B, Tillmanns T

Abstract
PURPOSE: The purpose of this document is to present a current and comprehensive set of practice recommendations for effective genetic cancer risk assessment, counseling and testing for hereditary breast and ovarian cancer. The intended audience is genetic counselors and other health professionals who care for individuals with, or at increased risk of, hereditary breast and/or ovarian cancer.

PMID: 23188549 [PubMed - in process]

The World Health Organization-United Nations Population Fund Strategic Partnership Programme's implementation of family planning guidelines and tools in Asia-Pacific countries.

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J Obstet Gynaecol Res. 2013 Apr;39(4):825-30

Authors: Mody SK, Ba-Thike K, Gaffield ME

Abstract
AIM: The aim of this study was to assess the impact of the Strategic Partnership Programme, a collaboration between the World Health Organization and the United Nations Population Fund to improve evidence-based guidance for country programs through the introduction of selected practice guidelines to improve sexual and reproductive health.
METHODS: Information for this report is from questionnaires sent to Ministries of Health in 2004 (baseline assessment) and in 2007 (assessment of outcome), annual country reports and personal communication with focal points from Ministries of Health and World Health Organization regional and country offices.
RESULTS: Following the Strategic Partnership Programme, family planning guidance was used extensively to: formulate and update reproductive health policy; update standards and guidelines; improve training curricula; conduct training activities; develop advocacy and communication materials; and promote change in service.
CONCLUSION: The Strategic Partnership Programme was successful in promoting the introduction of evidence-based guidelines for reproductive health in several Asian countries. The countries that adapted the family planning guidance observed an increase in demand for contraceptives commodities.

PMID: 23167754 [PubMed - in process]

Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study.

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Int J Nurs Stud. 2013 Apr;50(4):495-507

Authors: Milisen K, Coussement J, Arnout H, Vanlerberghe V, De Paepe L, Schoevaerdts D, Lambert M, Van Den Noortgate N, Delbaere K, Boonen S, Dejaeger E

Abstract
BACKGROUND: About 40% of all adverse events in hospital are falls, but only about one in three Belgian hospitals have a fall prevention policy in place. The implementation of a national practice guideline is urgently needed.
OBJECTIVE AND DESIGN: This multicentre study aimed to determine the feasibility of a previously developed guideline. SETTING, PARTICIPANTS AND METHOD: Seventeen geriatric wards, selected at random out of 40 Belgian hospitals who agreed to take part in the study, evaluated the fall prevention guideline. After the one-month test period, 49 healthcare workers completed a questionnaire on the feasibility of the guideline.
RESULTS: At the end of the study, 512 geriatric patients had been assessed using the practice guideline. The average time spent per patient on case finding, multifactorial assessment and initiating a treatment plan was 5.1, 76.1 and 30.6 min, respectively. For most risk assessments and risk modifications, several disciplines considered themselves as being responsible and capable. The majority (more than 69%) of the respondents judged the practice guideline as useful, but only a small majority (62.3%) believed that the guideline could be successfully integrated into their daily practice over a longer period of time. Barriers for implementation included a large time investment (81.1%), lack of communication between the different disciplines (35.8%), lack of motivation of the patient (34.0%), lack of multidisciplinary teamwork (28.3%), and lack of interest from the hospital management (15.4%).
CONCLUSION: Overall, the guideline was found useful, and for each risk factor (except for visual impairment), at least one discipline felt responsible and capable. Towards future implementation of the guideline, following steps should be considered: division of the risk-factor assessment duties and interventions among different healthcare workers; patient education; appointment of a fall prevention coordinator; development of a fall prevention policy with support from the management of the hospital.

PMID: 23116680 [PubMed - in process]

Editorial Comment from Dr Sengupta and Dr Webb to Pelvic lymph node dissection for prostate cancer: Adherence and accuracy of the recent guidelines.

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Int J Urol. 2013 Apr;20(4):412

Authors: Sengupta S, Webb DR

PMID: 23075160 [PubMed - in process]

Editorial Comment from Dr Laudone and Dr Silberstein to Pelvic lymph node dissection for prostate cancer: Adherence and accuracy of the recent guidelines.

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Int J Urol. 2013 Apr;20(4):411

Authors: Laudone VP, Silberstein JL

PMID: 23039361 [PubMed - in process]

Pelvic lymph node dissection for prostate cancer: Adherence and accuracy of the recent guidelines.

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Int J Urol. 2013 Apr;20(4):405-10

Authors: Abdollah F, Abdo A, Sun M, Schmitges J, Tian Z, Briganti A, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI

Abstract
OBJECTIVES: The 2004 National Comprehensive Cancer Network practice guidelines recommend pelvic lymph node dissection at radical prostatectomy. We sought to examine the adherence to the 2004 National Comprehensive Cancer Network guidelines and to test the their accuracy, as well as the accuracy of the most contemporary National Comprehensive Cancer Network, American Urological Association, and European Association of Urology guidelines to predict lymph node metastases.
METHODS: A total of 33 037 radical prostatectomy patients were identified, between 2004 and 2006. Adherence to the 2004 National Comprehensive Cancer Network guidelines was calculated using three clinically plausible cut-offs: 2, 5 and 10%. The accuracy was tested using the area under the curve.
RESULTS: Overall, 63% of patients underwent pelvic lymph node dissection. Of those, 61, 49 and 45% were managed according to the 2004 National Comprehensive Cancer Network guideline cut-off of 2, 5 and 10%, respectively. The accuracy of all the examined guidelines ranged from 61% to 71%. The highest accuracy was recorded for the European Association of Urology and the 2004 National Comprehensive Cancer Network cut-off 5% guidelines. The lowest accuracy was recorded for the most contemporary National Comprehensive Cancer Network guideline.
CONCLUSIONS: Adherence to the 2004 National Comprehensive Cancer Network guidelines was suboptimal. The accuracy of all the examined guidelines ranged from 61% to 71%. None of the examined guidelines can be regarded as an ideal indication for pelvic lymph node dissection.

PMID: 23039245 [PubMed - in process]

Evidence-based guideline recommendations on the use of positron emission tomography imaging in head and neck cancer.

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Clin Oncol (R Coll Radiol). 2013 Apr;25(4):e33-66

Authors: Yoo J, Henderson S, Walker-Dilks C

Abstract
AIMS: To provide evidence-based practice guideline recommendations on the use of fluoro-2-deoxy-D-glucose positron emission tomography (PET) for diagnosis, staging and assessing treatment response, restaging or recurrence of head and neck cancer.
MATERIALS AND METHODS: A systematic review by Facey et al. (Health Technology Assessment 2007;11(44):iii-iv, xi-267) was used as the evidence base for recommendation development. As the review was limited to August 2005, the evidence base was updated to July 2011 using the same search strategies for MEDLINE and EMBASE used in the original review. The authors of the current systematic review drafted recommendations, which were reviewed, adapted and accepted by consensus by the Ontario provincial Head and Neck Disease Site Group and a special meeting of clinical experts.
RESULTS: The results of the Facey et al. review for head and neck cancer included five other systematic reviews and 31 primary studies. The 2005 to 2011 update search included four additional systematic reviews and 53 primary studies. Recommendations were developed based on this evidence and accepted by consensus.
CONCLUSIONS: PET is recommended in the M and bilateral nodal staging of all patients with head and neck squamous cell carcinoma where conventional imaging is equivocal, or where treatment may be significantly modified. PET is recommended in all patients after conventional imaging and in addition to, or prior to, diagnostic panendoscopy where the primary site is unknown. PET is recommended for the staging and assessment of recurrence of patients with nasopharyngeal carcinoma if conventional imaging is equivocal. PET is recommended for restaging patients who are being considered for major salvage treatment, including neck dissection.

PMID: 23021712 [PubMed - in process]

Are the 2010 guidelines on cardiopulmonary resuscitation lost in translation? A call for increased focus on implementation science.

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Resuscitation. 2013 Apr;84(4):422-5

Authors: Dainty KN, Brooks SC, Morrison LJ

Abstract
Despite significant resources spent on rigorous evidence review and resuscitation guideline development, an important gap remains in our understanding of effective strategies and tools for implementing resuscitation guidelines. The lack of evidence about effective guideline implementation for resuscitation is likely reducing the impact of the incredible amount of work that goes into the production of such guidelines. This commentary draws attention to knowledge translation learnings from other content areas and within the area of resuscitation science to support a call for increased attention and innovation in implementation science as an equally important investment for the future of resuscitation medicine.

PMID: 22982993 [PubMed - in process]

Relevance of non-guideline studies for risk assessment: The coverage model based on most frequent targets in repeated dose toxicity studies.

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Toxicol Lett. 2013 Apr 26;218(3):293-8

Authors: Batke M, Aldenberg T, Escher S, Mangelsdorf I

Abstract
A common challenge for human risk assessment is the quality of the available animal studies. Non-guideline studies are often limited for different aspects of study design and documentation. Within this publication the relevance of a limited scope of examination is discussed. Preliminary analyses of the RepDose database have shown that liver, body weight, kidney and clinical symptoms are frequently affected in oral repeated dose toxicity in rats and mice (Bitsch et al., 2006), while many other targets are seldom affected. As most of these targets are investigated frequently also in non-guideline studies, it is likely that they provide a reliable NOEL, although the full spectrum of endpoints has not been covered. Based on RepDose data we investigate the relevance of individual targets for determining the LOEL and the consequences for risk assessment. The resulting coverage model for subchronic oral rat studies includes up to six targets and an additional assessment factor for LOEL extrapolation. It can be applied to assess the reliability of non-guideline studies with respect to the scope of examination. Furthermore the application of the coverage model to other databases will increase and/or specify the chemical domain and reveal respective targets as well as effects.

PMID: 22975263 [PubMed - in process]

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

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Int J Nurs Stud. 2013 Apr;50(4):464-74

Authors: Huis A, Schoonhoven L, Grol R, Donders R, Hulscher M, van Achterberg T

Abstract
BACKGROUND: Improving hand hygiene compliance is still a major challenge for most hospitals. Innovative approaches are needed.
OBJECTIVE: We tested whether an innovative, theory based, team and leaders-directed strategy would be more effective in increasing hand hygiene compliance rates in nurses than a literature based state-of-the-art strategy.
DESIGN AND SETTING: A cluster randomised controlled trial called HELPING HANDS was conducted in 67 nursing wards of three hospitals in the Netherlands.
PARTICIPANTS: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards).
METHODS: The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months. We monitored nurses' HH compliance during routine patient care before and directly after strategy delivery, as well as six months later. Secondary outcomes were compliance with each type of hand hygiene opportunity, the presence of jewellery and whether the nurses wore long-sleeved clothes. The effects were evaluated on an intention-to-treat basis by comparing the post-strategy hand hygiene compliance rates with the baseline rates. Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques.
RESULTS: During the study, we observed 10,785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1.64 (95% CI 1.33-2.02) in favour of the team and leaders-directed strategy.
CONCLUSIONS: Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues.
TRIAL REGISTRATION: ClinicalTrials.gov [NCT00548015].

PMID: 22939048 [PubMed - in process]