Januar 2013

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012.

Related Articles

Intensive Care Med. 2013 Jan 30;

Authors: Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R, The Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup*

Abstract
OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

PMID: 23361625 [PubMed - as supplied by publisher]

Guidelines for acquiring and reporting clinical neurospectroscopy.

Related Articles

Semin Neurol. 2012 Sep;32(4):432-53

Authors: Lin A, Tran T, Bluml S, Merugumala S, Liao HJ, Ross BD

Abstract
Since the advent of CPT 76390 in 1998, magnetic resonance spectroscopy (MRS) of the brain, or neurospectroscopy, has moved from the realm of academic research into that of the clinical world. All major MR manufacturers have aided in the endeavor by automating neurospectroscopy so that it no longer requires an MR physicist and is a push-button technique that can be run by technologists just as a typical MR sequence. Thousands of studies have demonstrated the clinical efficacy of neurospectroscopy, and there are many medical reviews of how this technique can be applied across a wide range of neurologic disorders. However, few studies address the practical issue of acquiring and reporting neurospectroscopy in a clinical practice. Based on clinical experience at three different sites across the country and nearly two decades of applications training for technologists and radiologists at international clinical neurospectroscopy courses, the guidelines described in this article demonstrate proven protocols for clinical diagnosis and outline the strategies involved in acquiring, interpreting, and reporting clinical neurospectroscopy successfully. A standard operating procedure used across the three sites is described and high reproducibility across different platforms is shown.

PMID: 23361487 [PubMed - in process]

Guidelines for automated preschool vision screening: A 10-year, evidence-based update.

Related Articles

J AAPOS. 2013 Jan 26;

Authors: Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB, AAPOS Vision Screening Committee

Abstract
SUMMARY: In 2003 the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee proposed criteria for automated preschool vision screening. Recent literature from epidemiologic and natural history studies, randomized controlled trials of amblyopia treatment, and field studies of screening technologies have been reviewed for the purpose of updating these criteria. The prevalence of amblyopia risk factors (ARF) is greater than previously suspected; many young children with low-magnitude ARFs do not develop amblyopia, and those who do often respond to spectacles alone. High-magnitude ARFs increase the likelihood of amblyopia. Although depth increases with age, amblyopia remains treatable until 60 months, with decline in treatment effectiveness after age 5. US Preventive Services Task Force Preventative Services Task Force guidelines allow photoscreening for children older than 36 months of age. Some technologies directly detect amblyopia rather than ARFs. Age-based criteria for ARF detection using photoscreening is prudent: referral criteria for such instruments should produce high specificity for ARF detection in young children and high sensitivity to detect amblyopia in older children. Refractive screening for ARFs for children aged 12-30 months should detect astigmatism >2.0 D, hyperopia >4.5 D, and anisometropia >2.5 D; for children aged 31-48 months, astigmatism >2.0 D, hyperopia > 4.0 D, and anisometropia >2.0 D. For children >49 months of age original criteria should be used: astigmatism >1.5 D, anisometropia>1.5 D, and hyperopia >3.5 D. Visually significant media opacities and manifest (not intermittent) strabismus should be detected at all ages. Instruments that detect amblyopia should report results using amblyopia presence as the gold standard. These new American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines will improve reporting of results and comparison of technologies.

PMID: 23360915 [PubMed - as supplied by publisher]

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

Related Articles

Int J Clin Pharm. 2013 Jan 29;

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 - as supplied by publisher]

Evidence-based guidelines and quality measures in the care of older adults.

Virtual Mentor. 2013;15(1):51-5

Authors: Ramsdale E, Dale W

PMID: 23356808 [PubMed - in process]

Assessment of cardiometabolic risk and prevalence of meeting treatment guidelines among patients with type 2 diabetes stratified according to their use of insulin and/or other diabetic medications: results from INSPIRE ME IAA.

Related Articles

Diabetes Obes Metab. 2013 Jan 28;

Authors: Smith J, Nazare JA, Borel AL, Aschner P, Barter PJ, Gaal LV, Matsuzawa Y, Kadowaki T, Ross R, Brulle-Wohlhueter C, Alméras N, Haffner SM, Balkau B

Abstract
Visceral adipose tissue (VAT) and liver fat are strongly associated with type 2 diabetes. It is not known, however, how diabetes treatment and/or risk factor management modulates the association between VAT, liver fat and diabetes. AIM: To determine the level of VAT and liver fat in patients with type 2 diabetes according to their treatment status and achievement of the American Diabetes Association's (ADA) diabetes management goals. METHODS: We performed a cross-sectional analysis of the baseline data of INSPIRE ME IAA, a 3-year prospective cardiometabolic imaging study conducted in 29 countries. Patients (n=3984) were divided into four groups: 1) those without type 2 diabetes (noT2D n=1003 men, n=1027 women); 2) those with type 2 diabetes but not treated with diabetes medications (T2Dnomeds n=248 men, n=191 women); 3) those with type 2 diabetes and treated with diabetes medications but not yet using insulin (T2Dmeds-ins n=591 men, n=484 women); and 4) those with type 2 diabetes and treated with insulin (T2Dmeds+ins n=233 men, n=207 women). Abdominal and liver adiposity were measured by computed tomography. RESULTS: Fewer patients with high VAT or liver fat achieved the ADA's goals for HDL-C or triglycerides compared to patients with low VAT or liver fat. Visceral adiposity (p=0.02 men, p=0.003 women) and liver fat (p=0.0002 men, p=0.0004 women) increased among patients who met fewer of the ADA treatment criteria, regardless of type 2 diabetes status or treatment. CONCLUSION: Residual cardiometabolic risk exists among patients with type 2 diabetes characterized by elevated VAT and liver fat.

PMID: 23356633 [PubMed - as supplied by publisher]

Going DEEP: guidelines for building simulation-based team assessments.

BMJ Qual Saf. 2013 Jan 25;

Authors: Grand JA, Pearce M, Rench TA, Chao GT, Fernandez R, Kozlowski SW

Abstract
BACKGROUND: Whether for team training, research or evaluation, making effective use of simulation-based technologies requires robust, reliable and accurate assessment tools. Extant literature on simulation-based assessment practices has primarily focused on scenario and instructional design; however, relatively little direct guidance has been provided regarding the challenging decisions and fundamental principles related to assessment development and implementation. OBJECTIVE: The objective of this manuscript is to introduce a generalisable assessment framework supplemented by specific guidance on how to construct and ensure valid and reliable simulation-based team assessment tools. The recommendations reflect best practices in assessment and are designed to empower healthcare educators, professionals and researchers with the knowledge to design and employ valid and reliable simulation-based team assessments. OVERVIEW: Information and actionable recommendations associated with creating assessments of team processes (non-technical 'teamwork' activities) and performance (demonstration of technical proficiency) are presented which provide direct guidance on how to Distinguish the underlying competencies one aims to assess, Elaborate the measures used to capture team member behaviours during simulation activities, Establish the content validity of these measures and Proceduralise the measurement tools in a way that is systematically aligned with the goals of the simulation activity while maintaining methodological rigour (DEEP). SUMMARY: The DEEP framework targets fundamental principles and critical activities that are important for effective assessment, and should benefit healthcare educators, professionals and researchers seeking to design or enhance any simulation-based assessment effort.

PMID: 23355693 [PubMed - as supplied by publisher]

[New guidelines on chronic pancreatitis : Interdisciplinary treatment strategies.]

Related Articles

Chirurg. 2013 Jan 26;

Authors: Lerch MM, Bachmann KA, Izbicki JR

Abstract
Chronic pancreatitis is a common disorder associated with significant morbidity and mortality. Interdisciplinary consensus guidelines have recently updated the definitions and diagnostic criteria for chronic pancreatitis and provide a critical assessment of therapeutic procedures. Diagnostic imaging relies on endoscopic ultrasound (EUS) as the most sensitive technique, whereas computed tomography (CT) and magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) remain a frequent preoperative requirement. Endoscopic retrograde cholangiopancreatography (ERCP) is now used mostly as a therapeutic procedure except for the differential diagnosis of autoimmune pancreatitis. Complications of chronic pancreatitis, such as pseudocysts, duct stricture and intractable pain can be treated with endoscopic interventions as well as open surgery. In the treatment of pseudocysts endoscopic drainage procedures now prevail while pain treatment has greater long-term effectiveness following surgical procedures. Currently, endocopic as well as surgical treatment of chronic pancreatitis require an ever increasing degree of technical and medical expertise and are provided increasingly more often by interdisciplinary centres. Surgical treatment is superior to interventional therapy regarding the outcome of pain control and duodenum-preserving pancreatic head resection is presently the surgical procedure of choice.

PMID: 23354556 [PubMed - as supplied by publisher]

Current obstetric guidelines on thromboprophylaxis in the United Kingdom: evidence based medicine?

Related Articles

Eur J Obstet Gynecol Reprod Biol. 2013 Jan 23;

Authors: Wu P, Poole TC, Pickett JA, Bhat A, Lees CC

Abstract
In the United Kingdom, the national guidance from Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Clinical Excellence (NICE) encourages the use of low molecular weight heparin thromboprophylaxis in high risk pregnancies. The recommendation, however, is based largely on expert opinion with almost no evidence from randomised controlled trials or meta-analyses. Here we examine the evidence for and against use of thromboprophylaxis and suggest that careful consideration is needed in implementing change in practice with follow-up of complications due to a real risk of unintended consequences. Therefore, large-scale and well-designed studies are urgently needed. We find that health economic assessments, which should be central to any major health policy change, appear entirely absent in this context.

PMID: 23352620 [PubMed - as supplied by publisher]

The effect of improved compliance with hygiene guidelines on transmission of Staphylococcus aureus to newborn infants: The Swedish Hygiene Intervention and Transmission of S aureus study.

Related Articles

Am J Infect Control. 2013 Jan 23;

Authors: Mernelius S, Löfgren S, Lindgren PE, Blomberg M, Olhager E, Gunnervik C, Lenrick R, Thrane MT, Isaksson B, Matussek A

Abstract
BACKGROUND: Newborn infants are often colonized with Staphylococcus aureus originating from health care workers (HCWs). We therefore use colonization with S aureus of newborn infants to determine the effect of an improved compliance with hygiene guidelines on bacterial transmission. METHODS: Compliance with hygiene guidelines was monitored prior to (baseline) and after (follow-up) a multimodal hygiene intervention in 4 departments of obstetrics and gynecology. spa typing was used to elucidate transmission routes of S aureus collected from newborn infants, mothers, fathers, staff members, and environment. RESULTS: The compliance with hygiene guidelines increased significantly from baseline to follow-up. The transmission of S aureus from HCWs to infants was however not affected. Fathers had the highest colonization rates. Persistent carriage was indicated in 18% of the HCWs. The most commonly isolated spa type was t084, which was not detected in a previous study from the same geographic area. CONCLUSION: It is possible to substantially improve the compliance with hygiene guidelines, by using multimodal hygiene intervention. The improved compliance did not decrease the transmission of S aureus from sources outside the own family to newborn infants. Furthermore, we show the establishment of a new spa type (t084), which now is very common in our region.

PMID: 23352076 [PubMed - as supplied by publisher]

A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of hypertension.

Related Articles

PLoS One. 2013;8(1):e53744

Authors: Al-Ansary LA, Tricco AC, Adi Y, Bawazeer G, Perrier L, Al-Ghonaim M, Alyousefi N, Tashkandi M, Straus SE

Abstract
BACKGROUND: Despite the availability of clinical practice guidelines (CPGs), optimal hypertension control is not achieved in many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To systematically review the quality, methodology, and consistency of recommendations of recently-developed national CPGs on the diagnosis, assessment and the management of hypertension.
METHODOLOGY/PRINCIPAL FINDINGS: MEDLINE, EMBASE, guidelines' websites and Google were searched for CPGs written in English on the general management of hypertension in any clinical setting published between January 2006 and September 2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently extracted the data. Conflicts were resolved by discussion or the involvement of an additional reviewer. Eleven CPGs were identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for "clarity of presentation" (44.4% -88.9%) and the lowest were for "rigour of development" (8.3%-30% for 9 CGPs). None of them clearly reported being newly developed or adapted. Only one reported having a patient representative in its development team. Systematic reviews were not consistently used and only 2 up-to-date Cochrane reviews were cited. Two CPGs graded some recommendations and related that to levels (but not quality) of evidence. The CPGs' recommendations on assessment and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment, adjustment of therapy and drug combinations. Important specific aspects of care (e.g. resistant hypertension) were ignored by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less variation of care or in better health-related outcomes.
CONCLUSIONS/SIGNIFICANCE: More efforts are needed to promote the realistic approach of localization or local adaptation of existing high-quality CPGs to the national context.

PMID: 23349738 [PubMed - in process]

Expert Guidelines for the Management of Alport Syndrome and Thin Basement Membrane Nephropathy.

J Am Soc Nephrol. 2013 Jan 24;

Authors: Savige J, Gregory M, Gross O, Kashtan C, Ding J, Flinter F

Abstract
Few prospective, randomized controlled clinical trials address the diagnosis and management of patients with Alport syndrome or thin basement membrane nephropathy. Adult and pediatric nephrologists and geneticists from four continents whose clinical practice focuses on these conditions have developed the following guidelines. The 18 recommendations are based on Level D (Expert opinion without explicit critical appraisal, or based on physiology, bench research, or first principles-National Health Service category) or Level III (Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees-U.S. Preventive Services Task Force) evidence. The recommendations include the use of genetic testing as the gold standard for the diagnosis of Alport syndrome and the demonstration of its mode of inheritance; the need to identify and follow all affected members of a family with X-linked Alport syndrome, including most mothers of affected males; the treatment of males with X-linked Alport syndrome and individuals with autosomal recessive disease with renin-angiotensin system blockade, possibly even before the onset of proteinuria; discouraging the affected mothers of males with X-linked Alport syndrome from renal donation because of their own risk of kidney failure; and consideration of genetic testing to exclude X-linked Alport syndrome in some individuals with thin basement membrane nephropathy. The authors recognize that as evidence emerges, including data from patient registries, these guidelines will evolve further.

PMID: 23349312 [PubMed - as supplied by publisher]

Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part I: Locoregional extension assessment: 2012 SFORL guidelines.

Related Articles

Eur Ann Otorhinolaryngol Head Neck Dis. 2013 Jan 21;

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

Abstract
OBJECTIVES: To set out good practice guidelines for locoregional extension assessment of squamous cell carcinoma of the head and neck (excluding nasopharynx, nasal cavities and sinuses). MATERIALS AND METHODS: A critical multidisciplinary review of the literature on locoregional extension assessment of squamous cell carcinoma of the head and neck was conducted, applying levels of evidence in line with the French health authority's (HAS) literature analysis guide of January 2000. CONCLUSION: Based on the levels of evidence of the selected articles and on work-group consensus, graded guidelines are set out for clinical, endoscopic and imaging locoregional extension assessment of head and neck cancer.

PMID: 23347771 [PubMed - as supplied by publisher]

Protocol for development of the guideline for reporting evidence based practice educational interventions and teaching (GREET) statement.

Related Articles

BMC Med Educ. 2013 Jan 25;13(1):9

Authors: Phillips AC, Lewis LK, McEvoy MP, Galipeau J, Glasziou P, Hammick M, Moher D, Tilson J, Williams MT

Abstract
ABSTRACT: BACKGROUND: There are an increasing number of studies reporting the efficacy of educational strategies to facilitate the development of knowledge and skills underpinning evidence based practice (EBP). To date there is no standardised guideline for describing the teaching, evaluation, context or content of EBP educational strategies. The heterogeneity in the reporting of EBP educational interventions makes comparisons between studies difficult. The aim of this program of research is to develop the Guideline for Reporting EBP Educational interventions and Teaching (GREET) statement and an accompanying explanation and elaboration (E&E) paper.Methods/design: Three stages are planned for the development process. Stage one will comprise a systematic review to identify features commonly reported in descriptions of EBP educational interventions. In stage two, corresponding authors of articles included in the systematic review and the editors of the journals in which these studies were published will be invited to participate in a Delphi process to reach consensus on items to be considered when reporting EBP educational interventions. The final stage of the project will include the development and pilot testing of the GREET statement and E&E paper.Outcome: The final outcome will be the creation of a Guideline for Reporting EBP Educational interventions and Teaching (GREET) statement and E&E paper. DISCUSSION: The reporting of health research including EBP educational research interventions, have been criticised for a lack of transparency and completeness. The development of the GREET statement will enable the standardised reporting of EBP educational research. This will provide a guide for researchers, reviewers and publishers for reporting EBP educational interventions.

PMID: 23347417 [PubMed - as supplied by publisher]

Use of Electronic Medical Record-Based Tools to Improve Compliance With Cervical Cancer Screening Guidelines: Effect of an Educational Intervention on Physicians' Practice Patterns.

Related Articles

J Low Genit Tract Dis. 2013 Jan 22;

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 - as supplied by publisher]

[New guidelines on functional and somatoform disorders].

Related Articles

Psychother Psychosom Med Psychol. 2013 Jan;63(1):26-31

Authors: Hausteiner-Wiehle C, Schäfert R, Sattel H, Ronel J, Herrmann M, Häuser W, Martin A, Henningsen P

Abstract
The S3 guideline "Dealing with patients with non-specific, functional and somatoform bodily symptoms" emphasizes the similarities in the management of the manifold manifestations of so called "medically unexplained symptoms" and gives recommendations for a stepped and collaborative diagnostic and therapeutic approach in all subspecialties and all levels of health care. It has a special focus on recommendations regarding attitude, physician-patient-relationship, communication, the parallelization of somatic and psychosocial diagnostics and a stepped therapeutic approach. The "Evidence-based guideline psychotherapy in somatoform disorders and associated syndromes" provides a differentiated analysis of the current evidence regarding the effectiveness of various psychotherapeutic interventions for the most relevant manifestations of functional and somatoform disorders. In combination, both guidelines pose important advances for treatment quality in Germany, but also illustrate remarkable structural and research deficits.

PMID: 23341111 [PubMed - in process]

Guidelines enforcement and clinical outcome.

Related Articles

Intern Emerg Med. 2013 Jan 22;

Authors: Santovito D, Di Iorio L, Mammarella C, Di Lembo E, Paganelli C, Mezzetti A, Cipollone F

PMID: 23338149 [PubMed - as supplied by publisher]

Putting the Dietary Guidelines for Americans into Action: Behavior-Directed Messages to Motivate Parents-Phase III Quantitative Message Testing and Survey Evaluation.

Related Articles

J Acad Nutr Diet. 2013 Jan 18;

Authors: Kapsak WR, Smith Edge M, White C, Childs NM, Geiger CJ

PMID: 23337657 [PubMed - as supplied by publisher]

Genetic screening in the American Society for Reproductive Medicine's new guidelines on diagnostic evaluation of the infertile male.

Related Articles

Fertil Steril. 2013 Jan 18;

Authors: Piña-Aguilar RE

PMID: 23337589 [PubMed - as supplied by publisher]

Compliance with hygiene guidelines: The effect of a multimodal hygiene intervention and validation of direct observations.

Related Articles

Am J Infect Control. 2013 Jan 19;

Authors: Mernelius S, Svensson PO, Rensfeldt G, Davidsson E, Isaksson B, Löfgren S, Matussek A

Abstract
BACKGROUND: Good compliance with hygiene guidelines is essential to prevent bacterial transmission and health care-associated infections. However, the compliance is usually <50%. METHODS: A multimodal and multidisciplinary hygiene intervention was launched once the baseline compliance was determined through direct observations in 4 departments of obstetrics and gynecology. Detailed evaluations of the compliance rates were performed at point of stability (at 80%) and follow-up (3 years after hygiene intervention). Validation of direct observations was performed using blinded double appraisal and multiappraisal. RESULTS: At baseline, the compliance with barrier precautions and the dress code at the 4 departments were 39% to 47% and 79% to 98%, respectively. Point of stability was reached approximately 1 year after the hygiene intervention was launched. The compliance with barrier precautions was significantly higher at follow-up compared with baseline in 3 departments. In the validation by double appraisal, 471 of 483 components were judged identical between observers. In the multiappraisal, 95% to 100% of the observers correctly judged the 7 components. CONCLUSION: It is possible to improve compliance with hygiene guidelines, but, to ensure a long-lasting effect, a continuous focus on barrier precautions is required. Observation is a valid method to monitor compliance.

PMID: 23337307 [PubMed - as supplied by publisher]

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 Jan 21;

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 - as supplied by publisher]

Evidence-based clinical practice guidelines on management of pain in older people.

Age Ageing. 2013 Jan 18;

Authors: Abdulla A, Bone M, Adams N, Elliott AM, Jones D, Knaggs R, Martin D, Sampson EL, Schofield P

PMID: 23335785 [PubMed - as supplied by publisher]

Lack of compliance of European Public Assessment Reports to guidelines for paediatric drug development before the introduction of paediatric investigation plans.

Clin Trials. 2013 Jan 18;

Authors: Piana C, Kliphuis E, Della Pasqua O

Abstract
BACKGROUND: According to the International Conference on Harmonisation (ICH) and Food and Drug Administration (FDA) guidelines for paediatric clinical trials, bridging procedures can be used if disease progression, exposure-response relationships, and clinical endpoints are similar in adults and children. In these circumstances, confirmatory efficacy trials are not necessary; the evaluation of pharmacokinetics and safety ought to be sufficient for drug approval. PURPOSE: The aim of this study was to assess whether the clinical trials and strategy for market approval authorisation (MAAs) in paediatric indications reflect the guidelines for bridging of adult data. METHODS: A total of 95 European Public Assessment Reports (EPARs) published between 1995 and 2007 were reviewed. From every report, data extraction was performed according to the phase of development, scope of analysis, number of dose levels, dosage form, and demographics of the subjects enrolled in the trial. Data analysis consisted of an initial grouping of the studies by the degree of compliance to bridging guidelines. RESULTS: Our analysis reveals that only 66% of the trials (n = 174) can be classified as needed, while 22% of the trials (n = 59) could have been designed and performed differently from the approved protocol (partially required). Moreover, 12% (n = 30) of the studies were deemed completely unnecessary. LIMITATIONS: A potential limitation in our study was that the dates of start and completion of the clinical studies were not available. Therefore, some EPARs have been included that may reflect common practice in the period that precedes the introduction of the ICH E11 guidelines. Yet, this should not obscure the points identified with regard to the lack of compliance to guidelines before the introduction of the paediatric legislation and the requirements for a paediatric investigation plan. CONCLUSIONS: Paediatric trials are desirable and necessary to address important unmet medical needs. However, the types of studies supporting regulatory approval do not always reflect the recommendations available in paediatric guidelines, which allow for extrapolation and bridging approaches. This situation may be explained by the lack of awareness about the prerequisites for the use of bridging concepts and of a clear process for evaluating different strategies in paediatric development.

PMID: 23335676 [PubMed - as supplied by publisher]

Do laboratories follow heart failure recommendations and guidelines and did we improve? The CARdiac MArker Guideline Uptake in Europe (CARMAGUE).

Clin Chem Lab Med. 2013 Jan 19;:1-6

Authors: Hammerer-Lercher A, Collinson P, van Dieijen-Visser MP, Pulkki K, Suvisaari J, Ravkilde J, Stavljenic-Rukavina A, Baum H, Laitinen P

Abstract
Abstract Background: Natriuretic peptides (NP) are well-established markers of heart failure (HF). During the past 5 years, analytical and clinical recommendations for measurement of these biomarkers have been published in guidelines. The aim of this follow-up survey was to investigate how well these guidelines for measurement of NP have been implemented in laboratory practice in Europe. Methods: Member societies of the European Federation of Clinical Chemistry and Laboratory Medicine were invited in 2009 to participate in a web-based audit questionnaire. The questionnaire requested information on type of tests performed, decision limits for HF, turn-around time and frequency of testing. Results: There was a moderate increase (12%) of laboratories measuring NP compared to the initial survey in 2006. The most frequently used HF decision limits for B-type NP (BNP) and N-terminal BNP (NT-proBNP) were, respectively, 100 ng/L and 125 ng/L, derived from the package inserts in 55%. Fifty laboratories used a second decision limit. Age or gender dependent decision limits were applied in 10% (8.5% in 2006). The vast majority of laboratories (80%) did not have any criteria regarding frequency of testing, compared to 33% in 2006. Conclusions: The implementation of NP measurement for HF management was a slow process between 2006 and 2009 at a time when guidelines had just been established. The decision limits were derived from package insert information and literature. There was great uncertainty concerning frequency of testing which may reflect the debate about the biological variability which was not published for most of the assays in 2009.

PMID: 23334056 [PubMed - as supplied by publisher]

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 4th Edition.

Pain Med. 2013 Jan 17;

Authors: Harden RN, Oaklander AL, Burton AW, Perez RS, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S

Abstract
OBJECTIVE: This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy). METHODS: Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking. RESULTS: The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature. CONCLUSIONS: In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.

PMID: 23331950 [PubMed - as supplied by publisher]

International guidelines for the in vivo assessment of skin properties in non-clinical settings: Part 2. transepidermal water loss and skin hydration.

Skin Res Technol. 2013 Jan 19;

Authors: Plessis JD, Stefaniak A, Eloff F, John S, Agner T, Chou TC, Nixon R, Steiner M, Franken A, Kudla I, Holness L

Abstract
BACKGROUND: There is an emerging perspective that it is not sufficient to just assess skin exposure to physical and chemical stressors in workplaces, but that it is also important to assess the condition, i.e. skin barrier function of the exposed skin at the time of exposure. The workplace environment, representing a non-clinical environment, can be highly variable and difficult to control, thereby presenting unique measurement challenges not typically encountered in clinical settings. METHODS: An expert working group convened a workshop as part of the 5th International Conference on Occupational and Environmental Exposure of Skin to Chemicals (OEESC) to develop basic guidelines and best practices (based on existing clinical guidelines, published data, and own experiences) for the in vivo measurement of transepidermal water loss (TEWL) and skin hydration in non-clinical settings with specific reference to the workplace as a worst-case scenario. RESULTS: Key elements of these guidelines are: (i) to minimize or recognize, to the extent feasible, the influences of relevant endogenous-, exogenous-, environmental- and measurement/instrumentation-related factors; (ii) to measure TEWL with a closed-chamber type instrument; (iii) report results as a difference or percent change (rather than absolute values); and (iv) accurately report any notable deviations from this guidelines. CONCLUSION: It is anticipated that these guidelines will promote consistent data reporting, which will facilitate inter-comparison of study results.

PMID: 23331328 [PubMed - as supplied by publisher]

Australia's dietary guidelines and the environmental impact of food "from paddock to plate".

Related Articles

Med J Aust. 2013 Jan 21;198(1):18-9

Authors: Selvey LA, Carey MG

PMID: 23330750 [PubMed - in process]

Impact of remuneration on guideline adherence: Empirical evidence in general practice.

Related Articles

Scand J Prim Health Care. 2013 Jan 21;

Authors: van Dijk CE, Verheij RA, Spreeuwenberg P, van den Berg MJ, Groenewegen PP, Braspenning J, de Bakker DH

Abstract
Background and objective. Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated. Design and setting. A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence. Subjects. 21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs). Main outcome measures. Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions. Results. Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients. Conclusion. The change in the remuneration system had a limited impact on guideline adherence.

PMID: 23330604 [PubMed - as supplied by publisher]

Poor adherence to guidelines for long-term oxygen therapy (LTOT) in two Italian university hospitals.

Related Articles

Intern Emerg Med. 2013 Jan 18;

Authors: Verduri A, Ballerin L, Simoni M, Cellini M, Vagnoni E, Roversi P, Papi A, Clini E, Fabbri LM, Potena A

Abstract
Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. The aim of our study was to examine retrospectively the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT between January 2005 and December 2006 in two Italian university hospitals (Ferrara and Modena). Out of a total of 191 medical records of patients prescribed LTOT, only 157 had adequate clinical data considering the three main criteria for appropriateness (arterial blood gas and/or pulse oximetry measurement, oxygen administration, smoking status). Out of these 157 patients, only 73 (46.5 %) fulfilled all three criteria recommended by the guidelines. Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored.

PMID: 23329404 [PubMed - as supplied by publisher]

Human computation as a new method for evidence-based knowledge transfer in web-based guideline development groups: proof of concept randomized controlled trial.

Related Articles

J Med Internet Res. 2013;15(1):e8

Authors: Heselmans A, Aertgeerts B, Donceel P, Van de Velde S, Vanbrabant P, Ramaekers D

Abstract
BACKGROUND: Guideline developers use different consensus methods to develop evidence-based clinical practice guidelines. Previous research suggests that existing guideline development techniques are subject to methodological problems and are logistically demanding. Guideline developers welcome new methods that facilitate a methodologically sound decision-making process. Systems that aggregate knowledge while participants play a game are one class of human computation applications. Researchers have already proven that these games with a purpose are effective in building common sense knowledge databases.
OBJECTIVE: We aimed to evaluate the feasibility of a new consensus method based on human computation techniques compared to an informal face-to-face consensus method.
METHODS: We set up a randomized design to study 2 different methods for guideline development within a group of advanced students completing a master of nursing and obstetrics. Students who participated in the trial were enrolled in an evidence-based health care course. We compared the Web-based method of human-based computation (HC) with an informal face-to-face consensus method (IC). We used 4 clinical scenarios of lower back pain as the subject of the consensus process. These scenarios concerned the following topics: (1) medical imaging, (2) therapeutic options, (3) drugs use, and (4) sick leave. Outcomes were expressed as the amount of group (dis)agreement and the concordance of answers with clinical evidence. We estimated within-group and between-group effect sizes by calculating Cohen's d. We calculated within-group effect sizes as the absolute difference between the outcome value at round 3 and the baseline outcome value, divided by the pooled standard deviation. We calculated between-group effect sizes as the absolute difference between the mean change in outcome value across rounds in HC and the mean change in outcome value across rounds in IC, divided by the pooled standard deviation. We analyzed statistical significance of within-group changes between round 1 and round 3 using the Wilcoxon signed rank test. We assessed the differences between the HC and IC groups using Mann-Whitney U tests. We used a Bonferroni adjusted alpha level of .025 in all statistical tests. We performed a thematic analysis to explore participants' arguments during group discussion. Participants completed a satisfaction survey at the end of the consensus process.
RESULTS: Of the 135 students completing a master of nursing and obstetrics, 120 participated in the experiment. We formed 8 HC groups (n=64) and 7 IC groups (n=56). The between-group comparison demonstrated that the human computation groups obtained a greater improvement in evidence scores compared to the IC groups, although the difference was not statistically significant. The between-group effect size was 0.56 (P=.30) for the medical imaging scenario, 0.07 (P=.97) for the therapeutic options scenario, and 0.89 (P=.11) for the drug use scenario. We found no significant differences in improvement in the degree of agreement between HC and IC groups. Between-group comparisons revealed that the HC groups showed greater improvement in degree of agreement for the medical imaging scenario (d=0.46, P=.37) and the drug use scenario (d=0.31, P=.59). Very few evidence arguments (6%) were quoted during informal group discussions.
CONCLUSIONS: Overall, the use of the IC method was appropriate as long as the evidence supported participants' beliefs or usual practice, or when the availability of the evidence was sparse. However, when some controversy about the evidence existed, the HC method outperformed the IC method. The findings of our study illustrate the importance of the choice of the consensus method in guideline development. Human computation could be an acceptable methodology for guideline development specifically for scenarios in which the evidence shows no resonance with participants' beliefs. Future research is needed to confirm the results of this study and to establish practical significance in a controlled setting of multidisciplinary guideline panels during real-life guideline development.

PMID: 23328663 [PubMed - in process]

Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial.

Related Articles

Implement Sci. 2013 Jan 18;8(1):8

Authors: Harris MF, Lloyd J, Litt J, van Driel M, Mazza D, Russell G, Smith J, Del Mar C, Denney-Wilson E, Parker S, Krastev Y, Jayasinghe UW, Taylor R, Zwar N, Wilson J, Bolger-Harris H, Waters J

Abstract
ABSTRACT: BACKGROUND: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. METHODS: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. DISCUSSION: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.

PMID: 23327664 [PubMed - as supplied by publisher]

[Guidelines and Conflicts of Interest: where are we, where do we go from here?].

Related Articles

Pneumologie. 2013 Jan;67(1):13-5

Authors: Ewig S, Schaberg T, Welte T, Ficker JH, Pfeifer M, Schönhofer B

PMID: 23325728 [PubMed - in process]

[German Guideline for Diagnosis and Management of Idiopathic Pulmonary Fibrosis.]

Related Articles

Pneumologie. 2013 Jan 16;

Authors: Behr J, Günther A, Ammenwerth W, Bittmann I, Bonnet R, Buhl R, Eickelberg O, Ewert R, Gläser S, Gottlieb J, Grohé C, Kreuter M, Kroegel C, Markart P, Neurohr C, Pfeifer M, Prasse A, Schönfeld N, Schreiber J, Sitter H, Theegarten D, Theile A, Wilke A, Wirtz H, Witt C, Worth H, Zabel P, Müller-Quernheim J, Costabel U

Abstract
Idiopathic pulmonary fibrosis is a fatal lung disease with a variable and unpredictable natural history and limited treatment options. Since publication of the ATS-ERS statement on IPF in the year 2000 diagnostic standards have improved and a considerable number of randomized controlled treatment trials have been published necessitating a revision. In the years 2006 - 2010 an international panel of IPF experts produced an evidence-based guideline on diagnosis and treatment of IPF, which was published in 2011. In order to implement this evidence-based guideline into the German Health System a group of German IPF experts translated and commented the international guideline, also including new publications in the field. A consensus conference was held in Bochum on December 3rd 2011 under the protectorate of the "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP)" and supervised by the "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften" (AWMF). Most recommendations of the international guideline were found to be appropriate for the german situation. Based on recent clinical studies "weak negative" treatment recommendations for pirfenidone and anticoagulation were changed into "weak positive" for pirfenidone and "strong negative" for anticoagulation. Based on negative results from the PANTHER-trial the recommendation for the combination therapy of prednisone plus azathiorpine plus N-acetlycsteine was also changed into strong negative für patients with definite IPF. This document summarizes essential parts of the international IPF guideline and the comments and recommendations of the German IPF consensus conference.

PMID: 23325398 [PubMed - as supplied by publisher]

Aspirin for the Prophylaxis of Venous Thromboembolic Events in Orthopedic Surgery Patients: A Comparison of the AAOS and ACCP Guidelines with Review of the Evidence.

Related Articles

Ann Pharmacother. 2013 Jan;47(1):63-74

Authors: Stewart DW, Freshour JE

Abstract
BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both developed evidence-based guidelines to prevent venous thromboembolism (VTE) in high-risk orthopedic surgery patients. Recent changes to these documents have brought them into agreement as to the inclusion of aspirin as an appropriate option for VTE prophylaxis in this patient population.
OBJECTIVE: To evaluate the appropriateness of aspirin to prevent VTE in high-risk orthopedic surgery patients.
DATA SOURCES: Guidelines published by the AAOS in 2011 and the ACCP in 2012 were compared regarding their recommendations on the use of aspirin for the prevention of VTE. A literature search was also conducted to identify clinical trials that evaluated the use of aspirin for the prevention of VTE in this patient population. Search terms included the MeSH terms venous thromboembolism; venous thrombosis; pulmonary embolism; aspirin; arthroplasty, replacement, knee; arthroplasty, replacement, hip; and hip fractures/surgery.
STUDY SELECTION AND DATA EXTRACTION: Any study that evaluated aspirin, even in combination with another method of prophylaxis (such as pneumatic compression devices), and had been published during or after 1985 was included.
DATA SYNTHESIS: Randomized controlled trials, meta-analyses, and other large pooled and retrospective reviews have failed to consistently arrive at similar conclusions regarding the efficacy and safety of aspirin as an option for VTE prophylaxis in patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or hip fracture surgery (HFS). Disagreements in the appropriateness of surrogate markers for safety and efficacy have resulted in differing recommendations from the ACCP and AAOS. The primary argument lies in the appropriateness of deep vein thrombosis as a surrogate marker for more serious outcomes such as pulmonary emboli.
CONCLUSIONS: Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants.

PMID: 23324504 [PubMed - in process]

Korean Guidelines for Pharmacoeconomic Evaluation (Second and Updated Version) : Consensus and Compromise.

Related Articles

Pharmacoeconomics. 2013 Jan 16;

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 - as supplied by publisher]

Treatment planning methodology for the Miami Multichannel Applicator following the American Brachytherapy Society recently published guidelines: the Lahey Clinic experience.

J Appl Clin Med Phys. 2013;14(1):4098

Authors: Iftimia I, Cirino ET, Mower HW, McKee AB

Abstract
The objective of this study was to develop a standardized procedure from simulation to treatment delivery for the multichannel Miami applicator, in order to increase planning consistency and reduce errors. A plan is generated prior to the 1st treatment using the CT images acquired with the applicator in place, and used for all 3 fractions. To confirm the application placement before each treatment fraction, an AP image is acquired and compared with the AP baseline image taken at simulation. A preplanning table is generated using the EBRT doses and is used to compute the maximum allowable D2cc for bladder, rectum, and sigmoid, and the mean allowable dose for the upper vaginal wall per HDR brachytherapy fraction. These data are used to establish the criteria for treatment planning dose optimization. A step-by-step treatment planning approach was developed to ensure appropriate coverage for the tumor (D90 &gt; 100% prescribed dose of 700 cGy/fraction) and the uninvolved vaginal surface (dose for the entire treatment length &gt; 600 cGy/fraction), while keeping the organs at risk below the tolerance doses. The equivalent dose 2 Gy (EQD2) tolerances for the critical structures are based on the American Brachytherapy Society (ABS) recently published guidelines. An independent second check is performed before the 1st treatment using an in-house Excel spreadsheet. This methodology was successfully applied for our first few cases. For these patients: the cumulative tumor dose was 74-79 EQD2 Gy10 (ABS recommended range 70-85); tumor D90 was &gt;100% of prescribed dose (range 101%-105%); cumulative D2cc for bladder, rectum, and sigmoid were lower than the tolerances of 90, 75, and 75 EQD2 Gy3, respectively; cumulative upper vaginal wall mean dose was below the tolerance of 120 EQD2 Gy3; the second check agreement was within 5%. By using a standardized procedure the planning consistency was increased and all dosimetric criteria were met.

PMID: 23318396 [PubMed - in process]

[Adherence between antibiotic prescriptions and guidelines in an internal medicine ward: An evaluation of professional practices.]

Related Articles

Rev Med Interne. 2013 Jan 11;

Authors: Peix C, Vandenhende MA, Bonnet F, Lacoste D, Bernard N, Youssef J, Hessamfar M, Pometan JP, Morlat P

Abstract
INTRODUCTION: This is an evaluation of professional practices (EPP) on antibiotic therapy in an internal medicine ward. MATERIAL AND METHODS: A 6-month prospective review of antibiotic prescriptions and their comparisons with local and national guidelines (drug, daily dose, administration, and duration) were performed. RESULTS: Antibiotic therapy on 227 infectious episodes was collected. According to local guidelines, we found 56% of totally respected (lower respiratory tract infections: 38%, urinary tract infections: 88% and skin infections: 73%), 33% of partially respected and 11% of non-appropriate prescriptions. Considering national guidelines for lower respiratory tract infections as references, the results were: totally respected prescriptions 81%, partially respected prescriptions 16%, and non-appropriate prescriptions 3%. CONCLUSION: This evaluation of the prescriptions allowed setting up long-lasting actions to improve clinical practice. This approach anticipates the procedures of EPP that will be needed for hospital accreditation and highlights the importance of considering several guidelines for the interpretation of the results.

PMID: 23318197 [PubMed - as supplied by publisher]

Development of simulator guidelines for resident assessment in flexible endoscopy.

Am Surg. 2013 Jan;79(1):14-22

Authors: Sutton E, Chase SC, Klein R, Zhu Y, Godinez C, Youssef Y, Park A

Abstract
Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE EndoscopyVR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners' knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

PMID: 23317591 [PubMed - in process]

AAP releases guideline on diagnosis, evaluation, and treatment of ADHD.

Related Articles

Am Fam Physician. 2013 Jan 1;87(1):61-2

Authors: Hauk L

PMID: 23317027 [PubMed - in process]

Health costs and consequences: have UK national guidelines had any effect on tonsillectomy rates and hospital admissions for tonsillitis?

Related Articles

Eur Arch Otorhinolaryngol. 2013 Jan 12;

Authors: Al-Hussaini A, Owens D, Tomkinson A

Abstract
Tonsillectomy is a common therapeutic option in the management of recurrent tonsillitis. In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) introduced SIGN 34 outlining appropriate indications for tonsillectomy. Following concerns of increasing hospital admissions for tonsillitis, in 2009 ENT UK suggested that too few tonsillectomies were being undertaken. This study analyses the effect the SIGN guidelines have had on trends in population rates of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess in England, Scotland and Wales. A retrospective study was undertaken using the health databases of England, Scotland and Wales between 1999 and 2010. Tonsillectomy, acute tonsillitis and peritonsillar abscess were identified using national classification codes. Changes in rate of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess were assessed using a linear regression model. 699,898 tonsillectomies were undertaken in the three national cohorts over the study period. Linear regression analysis suggested that implementation of SIGN 34 significantly reduced the population rate of tonsillectomy in England (p = 0.005) and Wales (p = 0.003) but not in Scotland (p = 0.24), and indicated there had been an increase in hospital admissions for acute tonsillitis in all cohorts (England p = 0.000008, Scotland p = 0.03, Wales p = 0.000005) and peritonsillar abscess in England (p < 0.05) and Wales (p = 0.03). SIGN 34 has reduced tonsillectomy rates in England and Wales but not in Scotland. This finding is associated with increasing hospital admissions for acute tonsillitis in all national cohorts, which may suggest that the current stipulated guidelines miss patients who would benefit from surgical intervention.

PMID: 23315186 [PubMed - as supplied by publisher]

Suggested guidelines for clinical and pathological assessment in African swine fever virus vaccine development.

Related Articles

Virus Res. 2013 Jan 11;

Authors: Galindo-Cardiel I, Ballester M, Solanes D, Nofrarías M, López-Soria S, Argilaget J, Lacasta A, Accensi F, Rodríguez F, Segalés J

Abstract
African swine fever is still one of the major viral diseases of swine for which a commercial vaccine is lacking. For the design and development of such preventive products, researchers involved in African swine fever virus (ASFV) vaccinology need standardized challenge protocols and well characterized clinical, pathological and immunological responses of inbreed and outbreed pigs to different viral strains and vaccine-like products. The different approaches used should be assessed by immunologist, virologist and pathologist expertise. The main objectives of this guideline are to (1) briefly contextualize the clinical and pathological ASFV presentations focusing on points that are critical for pathogenesis, (2) provide recommendations concerning the analysis of clinical, gross and microscopic observations and (3) standardize the pathological report, the terminology employed and the evaluation of the severity of the lesions between the ASFV research groups for comparing inter-group data. The presented guidelines establish new approaches to integrate such relevant pathological data with virological and immunological testing, giving support to the global interpretation of the findings in the future experiments of ASFV-related vaccinology and immunology.

PMID: 23313935 [PubMed - as supplied by publisher]

Perceived risk and adherence to breast cancer screening guidelines among women with a familial history of breast cancer: A review of the literature.

Related Articles

Breast. 2013 Jan 9;

Authors: Walker MJ, Chiarelli AM, Knight JA, Mirea L, Glendon G, Ritvo P

Abstract
OBJECTIVES: A small positive association has been consistently demonstrated between perceived breast cancer risk and mammography use. Evidence specific to women with familial breast cancer risk has not been previously reviewed. METHODS: A literature search was conducted. 186 studies were identified for abstract/full-text review, of which 10 articles were included. Manual searching identified 10 additional articles. Twenty articles examining the association between perceived breast cancer risk and adherence to mammography, clinical breast examination (CBE) or breast self-examination (BSE) guidelines among women with familial breast cancer risk were reviewed. Studies were classified according to screening modality, categorized by finding and ordered by year of publication. Studies assessing mammography were further classified according to the applied method of measuring perceived risk. RESULTS: Our review found a weak positive association between higher perceived risk and adherence to mammography guidelines among women with familial breast cancer risk. Consistent associations between perceived risk and adherence to CBE and BSE guidelines were not observed. CONCLUSIONS: Our ability to understand the relationship between perceived breast cancer risk and adherence to breast screening guidelines is limited, because most previous research is cross-sectional. Future studies with prospective methodologies that use consistent measurement methods and are adequately powered are warranted.

PMID: 23313062 [PubMed - as supplied by publisher]

GRADE guidelines: 15. Going from evidence to recommendations: the significance and presentation of recommendations.

Related Articles

J Clin Epidemiol. 2013 Jan 8;

Authors: Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, Nasser M, Meerpohl J, Post PN, Kunz R, Brozek J, Vist G, Rind D, Akl EA, Schünemann HJ

Abstract
This article describes the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to classifying the direction and strength of recommendations. The strength of a recommendation, separated into strong and weak, is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh its undesirable effects. Alternative terms for a weak recommendation include conditional, discretionary, or qualified. The strength of a recommendation has specific implications for patients, the public, clinicians, and policy makers. Occasionally, guideline developers may choose to make "only-in-research" recommendations. Although panels may choose not to make recommendations, this choice leaves those looking for answers from guidelines without the guidance they are seeking. GRADE therefore encourages panels to, wherever possible, offer recommendations.

PMID: 23312392 [PubMed - as supplied by publisher]

Impact of the 7th Edition AJCC Staging Classification on the NCCN Clinical Practice Guidelines in Oncology for Gastric and Esophageal Cancers.

Related Articles

J Natl Compr Canc Netw. 2013 Jan 1;11(1):60-6

Authors: Strong VE, D'Amico TA, Kleinberg L, Ajani J

Abstract
The 7th edition of the AJCC Cancer Staging Manual has attempted to harmonize gastric and esophageal cancers, including management of gastroesophageal junction (GEJ)-type tumors. The treatment of complex tumor types is best guided by a staging classification that reliably groups patients according to prognosis and therapy. This article reviews and discusses these changes with the goal of elucidating key features of the staging system and outlining how these changes relate to the NCCN Clinical Practice Guidelines in Oncology with regard to the care and treatment of patients. The 7th edition of the AJCC Cancer Staging Manual has certainly improved harmonization of gastric and distal esophageal/GEJ-type adenocarcinomas, although issues persist, particularly regarding the optimal neoadjuvant treatment for the management of GEJ carcinomas.

PMID: 23307982 [PubMed - in process]

Implementing Clinical Practice Guidelines About Health Promotion and Disease Prevention Through Shared Decision Making.

Related Articles

J Gen Intern Med. 2013 Jan 10;

Authors: Politi MC, Wolin KY, Légaré F

Abstract
Clinical practice guidelines aim to improve the health of patients by guiding individual care in clinical settings. Many guidelines specifically about health promotion or primary disease prevention are beginning to support informed patient choice, and suggest that clinicians and patients engage in shared discussions to determine how best to tailor guidelines to individuals. However, guidelines generally do not address how to translate evidence from the population to the individual in clinical practice, or how to engage patients in these discussions. In addition, they often fail to reconcile patients' preferences and social norms with best evidence. Shared decision making (SDM) is one solution to bridge guidelines about health promotion and disease prevention with clinical practice. SDM describes a collaborative process between patients and their clinicians to reach agreement about a health decision involving multiple medically appropriate treatment options. This paper discusses: 1) a brief overview of SDM; 2) the potential role of SDM in facilitating the implementation of prevention-focused practice guidelines for both preference-sensitive and effective care decisions; and 3) avenues for future empirical research to test how best to engage individual patients and clinicians in these complex discussions about prevention guidelines. We suggest that SDM can provide a structure for clinicians to discuss clinical practice guidelines with patients in a way that is evidence-based, patient-centered, and incorporates patients' preferences. In addition to providing a model for communicating about uncertainty at the individual level, SDM can provide a platform for engaging patients in a conversation. This process can help manage patients' and clinicians' expectations about health behaviors. SDM can be used even in situations with strong evidence for benefits at the level of the population, by helping patients and clinicians prioritize behaviors during time-pressured medical encounters. Involving patients in discussions could lead to improved health through better adherence to chosen options, reduced practice variation about preference-sensitive options, and improved care more broadly. However, more research is needed to determine the impact of this approach on outcomes such as morbidity and mortality.

PMID: 23307397 [PubMed - as supplied by publisher]

Cardiopulmonary resuscitation performance during simulator-based trainings - a comparative retrospective analysis of adherence to 2005 and 2010 guidelines.

Minerva Anestesiol. 2013 Jan 10;

Authors: Mayer V, Schulz CM, Kreuzer M, Wagner KJ, Schneider G, Kochs EF

Abstract
BACKGROUND: New cardiopulmonary resuscitation (CPR) guidelines have been published in 2010 emphasizing the importance of minimizing interruptions during chest compression. The aim of our study was to compare the simulator-based CPR training performance of physicians not specialized in anaesthesia and intensive care nurses before and after implementation of new resuscitation guidelines. METHODS: In autumn 2010, a total of 74 scenarios during six 1.5 day simulation-based CPR trainings were performed. Four of them were conducted after the implementation of the 2010 guidelines. During each simulated scenario a programmed script standardized the conditions of the simulator and its reactions on the trainees' actions. CPR relevant parameters were extracted on the basis of the simulator's log files and no-flowtime fraction and median cardiac output of the simulator were calculated. Results before and after the guideline implementation were compared using the Wilcoxon Two Sample Test. RESULTS: 34 out of 74 scenarios were included into the analysis. During training according to the 2010 guidelines, the no-flow-time fraction was lower (median: 21.8 % [IQR: 16.1-27.1 %] vs. 29.1 % [IQR: 25.0- 30.9 %]; p=0.04). The median cardiac output increased from 1.60 l*min-1 [IQR: 1.50-1.65 l*min-1] to 1.90 l*min-1 [IQR: 1.80-2.10 l*min-1]; p<0.001) when the CPR training was conducted according to the 2010 resuscitation guidelines. CONCLUSION: Non-anaesthesiological physicians and intensive care nurses training demonstrated an improved CPR performance in a high-fidelity human patient simulator with respect to the median cardiac output and duration of no-flow-time when 2010 CPR guidelines were applied.

PMID: 23306397 [PubMed - as supplied by publisher]

Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training the full staff of psychiatric departments via an e-learning supported Train-the-Trainer program: study protocol for a randomized controlled trial.

Related Articles

Trials. 2013;14(1):9

Authors: de Beurs DP, de Groot MH, de Keijser J, Verwey B, Mokkenstorm J, Twisk JW, van Duijn E, van Hemert AM, Verlinde L, Spijker J, van Luijn B, Vink J, Kerkhof AJ

Abstract
UNLABELLED: ABSTRACT:
BACKGROUND: In 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program.
METHOD: In a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments.
DISCUSSION: We aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study.
TRIAL REGISTRATION: Dutch trial register: NTR3092.

PMID: 23302322 [PubMed - in process]

Procedural pain in neonates: the state of the art in the implementation of national guidelines in Italy.

Paediatr Anaesth. 2013 Jan 10;

Authors: Lago P, Garetti E, Boccuzzo G, Merazzi D, Pirelli A, Pieragostini L, Piga S, Cuttini M, Ancora G

Abstract
BACKGROUND: National and international guidelines have been published on pain control and prevention in the newborn, but data on compliance with these guidelines are lacking. AIM: To document current hospital practices for analgesia at neonatal intensive care units (NICUs) 5 years after national guidelines were published in Italy. METHODS: A computer-based questionnaire was sent to all registered Italian level II and level III NICUs to investigate their routine pain control practices. MAIN OUTCOME MEASURES: The analgesia and sedation currently used for invasive procedures as compared with best practices. RESULTS: The questionnaire was returned by 103 of the 118 NICUs (87.3%), most of which (85.4%) knew of the national guidelines on procedural pain control and prevention, and used some analgesic measures during invasive procedures. One or more nonpharmacological interventions were only used routinely by 64.1% of the NICUs for heel pricks and venipuncture, 56.0% for percutaneous insertion of central catheters, 69.7% for nasal CPAP, and 62.4% for eye tests to screen for retinopathy of prematurity. Pain medication was routinely administered at 34.3% NICUs for tracheal intubation, 46.6% for mechanical ventilation (MV), 12.9% for tracheal aspiration, 71.4% for chest tube insertion, 33.0% for lumbar puncture, and 64.0% for postoperative pain. Pain was routinely monitored at only 22.7% of the units during MV, 12.1% for nCPAP, and 21.8% postoperatively. CONCLUSION: This survey showed that most Italian NICUs provide some form of analgesia and sedation for invasive procedures in accordance with national guidelines, but their routine adherence to best practices for pain control and monitoring is still suboptimal.

PMID: 23301982 [PubMed - as supplied by publisher]

Evidence-Based Clinical Practice Guidelines for Managing Depression in Persons Living With HIV.

Related Articles

J Assoc Nurses AIDS Care. 2013 Jan;24(1 Suppl):S15-28

Authors: Relf MV, Eisbach S, Okine KN, Ward T

Abstract
Depressive symptoms and depression are prevalent among persons living with HIV (PLWH). Depression among PLWH is associated with a lower quality of life, reduced adherence to antiretroviral treatment, poorer self-care, worsened treatment outcomes, greater impairment in social and vocational functioning, and increased social isolation. Assessment of depression in PLWH is critical to facilitate referral and management. Fortunately, two simple screening questions can be used to assess for depression, and evidence supports the effective management of depression for PLWH. First-line treatment regimens for depression include selective serotonin reuptake inhibitors (SSRIs), cognitive behavioral therapy (CBT), or a combination of SSRI and CBT. This paper examines the contemporary evidence related to depression in the context of HIV infection. A case study has been included to illustrate an application of evidence-based treatment interventions recommended for clinical practice.

PMID: 23290374 [PubMed - in process]

Evidence-Based Pain Guidelines in HIV Care.

Related Articles

J Assoc Nurses AIDS Care. 2013 Jan;24(1 Suppl):S112-26

Authors: Newshan G, Staats JA

Abstract
Despite advances in HIV treatment, pain continues to be a prevalent symptom experienced by persons living with HIV (PLWH) and is associated with sleep disturbance and lower quality of life. Ongoing assessments guide effective pain management. Substance abuse issues and concerns about diversion complicate pain treatment. We reviewed the evidence of current research related to pharmacological and nonpharmacological interventions for pain. A comprehensive review of the literature was conducted, including randomized controlled trials, meta-analyses, evidence-based clinical practice guidelines, and expert opinion; studies of HIV neuropathy and pediatric populations were excluded. We limited the search to English language and human studies. While pharmacology-based interventions are widespread, their efficacy over the long term is questionable. Nonpharmacological therapies are promising and require further study. Aberrant behaviors related to opiates are common in PLWH; expert guidelines to address them are presented. A case study is included to illustrate an application of evidence-based clinical practice.

PMID: 23290371 [PubMed - in process]

Developing Evidence-Based Symptom Management Guidelines in HIV Care: What Have We Learned?

Related Articles

J Assoc Nurses AIDS Care. 2013 Jan;24(1 Suppl):S1-4

Authors: Voss JG

PMID: 23290369 [PubMed - in process]

Efficient methods and practical guidelines for simulating isotope effects.

J Chem Phys. 2013 Jan 7;138(1):014112

Authors: Ceriotti M, Markland TE

Abstract
The shift in chemical equilibria due to isotope substitution is frequently exploited to obtain insight into a wide variety of chemical and physical processes. It is a purely quantum mechanical effect, which can be computed exactly using simulations based on the path integral formalism. Here we discuss how these techniques can be made dramatically more efficient, and how they ultimately outperform quasi-harmonic approximations to treat quantum liquids not only in terms of accuracy, but also in terms of computational cost. To achieve this goal we introduce path integral quantum mechanics estimators based on free energy perturbation, which enable the evaluation of isotope effects using only a single path integral molecular dynamics trajectory of the naturally abundant isotope. We use as an example the calculation of the free energy change associated with H/D and (16)O/(18)O substitutions in liquid water, and of the fractionation of those isotopes between the liquid and the vapor phase. In doing so, we demonstrate and discuss quantitatively the relative benefits of each approach, thereby providing a set of guidelines that should facilitate the choice of the most appropriate method in different, commonly encountered scenarios. The efficiency of the estimators we introduce and the analysis that we perform should in particular facilitate accurate ab initio calculation of isotope effects in condensed phase systems.

PMID: 23298033 [PubMed - in process]

Failure to identify antenatal multiple congenital contractures and fetal akinesia - proposal of guidelines to improve diagnosis.

Related Articles

Prenat Diagn. 2013 Jan;33(1):61-74

Authors: Filges I, Hall JG

Abstract
OBJECTIVE: The aim of this study is to assess the rate of prenatal detection of multiple congenital contractures, to identify reasons for the failure of prenatal diagnosis and to propose the first guidelines to improve prenatal diagnosis.
METHOD: We evaluated records on 107 individuals recognized at birth to have Amyoplasia. We reviewed the literature on the onset and development of fetal activity, antenatal clinical signs in fetal movement disorders, prenatal studies of fetal movement and contractures by ultrasound and magnetic resonance imaging (MRI) and existing guidelines.
RESULT: In 73.8%, the diagnosis was missed prenatally. Correct diagnosis was achieved by the identification of bilateral clubfeet on ultrasound or because mothers perceived reduced fetal movement. Ultrasound would be able to visualize contractures, joint positioning, the quality of fetal movements, lung size, muscle tissue, and bone growth in the first or early second trimester. MRI results are promising. Guidelines for assessing early fetal movement do not exist.
CONCLUSION: Prenatal detection rate of multiple congenital contractures is appalling. Failure of diagnosis precludes further etiologic and diagnostic workup and deprives families of making informed pregnancy choices. Standards for prenatal diagnosis are lacking, but on the basis of current knowledge and expert opinion, we propose the first guidelines for a prenatal diagnostic strategy, discuss future directions and the need for multicentric studies. © 2013 John Wiley & Sons, Ltd.

PMID: 23296716 [PubMed - in process]

Cervical Insufficiency: A New Issue for Guidelines on Prevention of Perinatal Group B Streptococcal Disease?

Related Articles

Pediatrics. 2013 Jan 6;

Authors: Natale F, Brunelli R, Bizzarri B, Castronovo A, De Curtis M

Abstract
The updated Guidelines on Prevention of Perinatal Group B Streptococcal Disease, issued by the Centers for Disease Control and Prevention, actually represent the mainstay in the prevention of neonatal early-onset group B streptococcal (GBS) sepsis. According to these guidelines, patients with possible preterm delivery are screened for GBS colonization and offered intrapartum prophylaxis only if they enter preterm labor or experience preterm premature rupture of the membranes. Nonetheless, the fulfillment of these recommendations seems to be suboptimal in clinical practice, as it is heavily influenced by the knowledge of the colonization status. We report here 2 cases of blood culture-proven, early-onset neonatal GBS sepsis involving preterm infants delivered by mothers who had midtrimester cervical insufficiency and bulging membranes. Midtrimester acute cervical insufficiency strongly predicts preterm delivery. These women are liable to miss intrapartum antibiotic prophylaxis because they typically have shorter labor, and the test results for GBS status are unlikely to be available before delivery. We believe that women with midtrimester cervical insufficiency and bulging membranes should be screened for GBS infection soon after hospital admittance if the gestational age is close to the threshold of fetal viability. A timely diagnosis of GBS colonization may not only increase the number of patients receiving targeted intrapartum antibiotic prophylaxis but would also allow consideration of the administration of antepartum antibiotic prophylaxis. Indeed, as further outlined in this report, GBS intraamniotic infection may dramatically occur before the onset of preterm labor or preterm premature rupture of the membranes.

PMID: 23296432 [PubMed - as supplied by publisher]

Implementing guidelines for follow-up after surgery with ventilation tube in the tympanic membrane in Norway: a retrospective study.

Related Articles

BMC Ear Nose Throat Disord. 2013 Jan 8;13(1):2

Authors: Austad B, Hetlevik I, Bugten V, Wennberg S, Olsen AH, Helvik AS

Abstract
ABSTRACT: BACKGROUND: When clinical guidelines are being changed a strategy is required for implementation. St. Olavs University Hospital in Norway modified their guidelines for the follow-up care of children after insertion of ventilation tubes (VT) in the tympanic membrane, transferring the controls of the healthiest children to General Practitioners (GPs). This study evaluates the implementation process in the hospital and in general practice by exploring two issues: 1) Whether the hospital discharged the patients they were supposed to and 2) whether the children consulted a GP for follow-up care. METHODS: A retrospective observational study was performed at St. Olavs University Hospital, Norway and general practice in Mid-Norway. Children under the age of 18 who underwent insertion of VT between Nov 1st 2007 and Dec 31st 2008 (n = 136) were included. Degree of guideline adherence at the hospital and in general practice was measured. RESULTS: The hospital adhered to the guidelines in two-thirds (68.5%) of the patients, planning more patients for follow-up by their GP than recommended in the guidelines (25.8% vs. 12.4%). All except one contacted their GP for control. In total 60% were referred back to specialist health services within two years. CONCLUSIONS: The methods for guideline implementation were successful in securing consultations for follow-up care in general practice. Lack of guideline adherence in the hospital can partly be explained by the lack of quality of the guideline. Further studies are needed to evaluate the quality of controls done by the GPs in order to consider implications for follow-up after VT surgery.

PMID: 23295016 [PubMed - as supplied by publisher]

Consensus guidelines for the management of atopic dermatitis: An Asia-Pacific perspective.

J Dermatol. 2013 Jan 5;

Authors: Rubel D, Thirumoorthy T, Soebaryo RW, Weng SC, Gabriel TM, Villafuerte LL, Chu CY, Dhar S, Parikh D, Wong LC, Lo KK, Asia-Pacific Consensus Group for Atopic Dermatitis

Abstract
Atopic dermatitis (AD) is a relatively common disease in patients in the Asia-Pacific region. It presents a particular clinical challenge and requires careful clinical management. The chronic nature of AD characterized by flares, exacerbations and periods of quiescence requires a multipronged approach aimed at reducing itch, inflammation and the appearance of secondary lesions. In addition, varying levels of maintenance therapy may be required to avoid exacerbations. Survey data from the region indicate that there is significant variation across the Asia-Pacific with regard to current treatment practices. The management of AD may also be influenced by differing health-care systems, variable climate, access to medical care and cultural diversity. The current consensus guidelines have been developed to provide up-to-date and concise evidence- and experience-based recommendations directed towards general practitioners and general dermatologists in the Asia-Pacific region on the management of pediatric and adult AD.

PMID: 23289827 [PubMed - as supplied by publisher]

Challenges and opportunities for implementing diabetes self-management guidelines.

Related Articles

J Am Board Fam Med. 2013 Jan;26(1):90-2

Authors: Appiah B, Hong Y, Ory MG, Helduser JW, Begaye D, Bolin JN, Forjuoh SN

Abstract
UNLABELLED: Purpose: The purpose of this article was to examine primary care providers' perceived challenges when implementing evidence-based diabetes self-management guidelines and opportunities for promoting the use of such guidelines in practice.
METHODS: We engaged 3 group discussions with 43 key stakeholders representing family physicians, medical directors, and quality assurance leaders in a large, university-affiliated, integrated health care organization in Central Texas. Transcripts from group discussions were summarized using thematic content analysis.
RESULTS: Key themes that emerged as challenges of implementing evidence-based diabetes self-management guidelines included lack of easily retrievable electronic patient health information, inadequate coordination with other health care providers when implementing guidelines, conflict between information in the guidelines and physicians' knowledge, and physician compensation by patient load rather than by quality of care. Two main opportunities identified were the use of health coaches or nurses trained in diabetes self-management and active collaboration between practicing providers and key stakeholders in the development and dissemination of guidelines.
CONCLUSION: Our study shows a need for involving front-line family physicians and other primary care providers as well as patients in the design and development of best practice guidelines to enhance implementation of diabetes self-management guidelines in primary care settings.

PMID: 23288286 [PubMed - in process]

ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing.

Related Articles

Genet Med. 2013 Jan 3;

Authors: Hickey SE, Curry CJ, Toriello HV

Abstract
MTHFR polymorphism testing is frequently ordered by physicians as part of the clinical evaluation for thrombophilia. It was previously hypothesized that reduced enzyme activity of MTHFR led to mild hyperhomocysteinemia which led to an increased risk for venous thromboembolism, coronary heart disease, and recurrent pregnancy loss. Recent meta-analyses have disproven an association between hyperhomocysteinemia and risk for coronary heart disease and between MTHFR polymorphism status and risk for venous t-hromboembolism. There is growing evidence that MTHFR polymorphism testing has minimal clinical utility and, therefore should not be ordered as a part of a routine evaluation for thrombophilia.Genet Med advance online publication 3 January 2013.Genetics in Medicine (2013); doi:10.1038/gim.2012.165.

PMID: 23288205 [PubMed - as supplied by publisher]

Minimizing ambiguity to promote the translation of evidence-based practice guidelines to reduce health care-associated infections.

Related Articles

Am J Infect Control. 2013 Jan;41(1):75-6

Authors: Hebden JN, Murphy C

PMID: 23287282 [PubMed - in process]

Evidence, guidelines and experience.

Related Articles

Drug Ther Bull. 2013 Jan;51(1):1

Authors:

PMID: 23284087 [PubMed - in process]

Adherence to healthy dietary guidelines and future depressive symptoms: evidence for sex differentials in the Whitehall II study.

Related Articles

Am J Clin Nutr. 2013 Feb;97(2):419-27

Authors: Akbaraly TN, Sabia S, Shipley MJ, Batty GD, Kivimaki M

Abstract
BACKGROUND: It has been suggested that dietary patterns are associated with future risk of depressive symptoms. However, there is a paucity of prospective data that have examined the temporality of this relation.
OBJECTIVE: We examined whether adherence to a healthy diet, as defined by using the Alternative Healthy Eating Index (AHEI), was prospectively associated with depressive symptoms assessed over a 5-y period.
DESIGN: Analyses were based on 4215 participants in the Whitehall II Study. AHEI scores were computed in 1991-1993 and 2003-2004. Recurrent depressive symptoms were defined as having a Center for Epidemiologic Studies Depression Scale score ≥16 or self-reported use of antidepressants in 2003-2004 and 2008-2009.
RESULTS: After adjustment for potential confounders, the AHEI score was inversely associated with recurrent depressive symptoms in a dose-response fashion in women (P-trend < 0.001; for 1 SD in AHEI score; OR: 0.59; 95% CI: 0.47, 0.75) but not in men. Women who maintained high AHEI scores or improved their scores during the 10-y measurement period had 65% (OR: 0.35%; 95% CI: 0.19%, 0.64%) and 68% (OR: 0.32%; 95% CI: 0.13%, 0.78%) lower odds of subsequent recurrent depressive symptoms than did women who maintained low AHEI scores. Among AHEI components, vegetable, fruit, trans fat, and the ratio of polyunsaturated fat to saturated fat components were associated with recurrent depressive symptoms in women.
CONCLUSION: In the current study, there was a suggestion that poor diet is a risk factor for future depression in women.

PMID: 23283506 [PubMed - in process]

SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study.

Related Articles

Implement Sci. 2013;8:3

Authors: Melman S, Schoorel EN, Dirksen C, Kwee A, Smits L, de Boer F, Jonkers M, Woiski MD, Mol BW, Doornbos JP, Visser H, Huisjes AJ, Porath MM, Delemarre FM, Kuppens SM, Aardenburg R, Van Dooren IM, Vrouenraets FP, Lim FT, Kleiverda G, van der Salm PC, de Boer K, Sikkema MJ, Nijhuis JG, Hermens RP, Scheepers HC

Abstract
UNLABELLED: ABSTRACT:
BACKGROUND: Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently.Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives).
METHODS: An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs.
DISCUSSION: This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child.
TRIAL REGISTRATION: http://www.clinicaltrials.gov: NCT01261676.

PMID: 23281646 [PubMed - in process]

Clinical practice guideline development manual, third edition: a quality-driven approach for translating evidence into action.

Otolaryngol Head Neck Surg. 2013 Jan;148(1 Suppl):S1-55

Authors: Rosenfeld RM, Shiffman RN, Robertson P

Abstract
BACKGROUND: Guidelines translate best evidence into best practice. A well-crafted guideline promotes quality by reducing health care variations, improving diagnostic accuracy, promoting effective therapy, and discouraging ineffective-or potentially harmful-interventions. Despite a plethora of published guidelines, methodology is often poorly defined and varies greatly within and among organizations.
PURPOSE: The third edition of this manual describes the principles and practices used successfully by the American Academy of Otolaryngology--Head and Neck Surgery Foundation to produce quality-driven, evidence-based guidelines using efficient and transparent methodology for actionable recommendations with multidisciplinary applicability. The development process emphasizes a logical sequence of key action statements supported by amplifying text, action statement profiles, and recommendation grades linking action to evidence. New material in this edition includes standards for trustworthy guidelines, updated classification of evidence levels, increased patient and public involvement, assessing confidence in the evidence, documenting differences of opinion, expanded discussion of conflict of interest, and use of computerized decision support for crafting actionable recommendations.
CONCLUSION: As clinical practice guidelines become more prominent as a key metric of quality health care, organizations must develop efficient production strategies that balance rigor and pragmatism. Equally important, clinicians must become savvy in understanding what guidelines are--and are not--and how they are best used to improve care. The information in this manual should help clinicians and organizations achieve these goals.

PMID: 23243141 [PubMed - in process]

Quality Improvement Guidelines for Percutaneous Management of Acute Lower-extremity Ischemia.

Related Articles

J Vasc Interv Radiol. 2013 Jan;24(1):3-15

Authors: Patel NH, Krishnamurthy VN, Kim S, Saad WE, Ganguli S, Gregory Walker T, Nikolic B

PMID: 23273693 [PubMed - in process]

Systematic Implementation of Evidence-Based Guidelines in Intensive Care Medicine: Resistance to Change is Human Nature*

Related Articles

Crit Care Med. 2013 Jan;41(1):329-331

Authors: Li Bassi G, Ranzani OT, Torres A

PMID: 23269134 [PubMed - as supplied by publisher]

Stereotactic radiosurgery guidelines for the management of patients with intracranial dural arteriovenous fistulas.

Prog Neurol Surg. 2013;27:218-26

Authors: Niranjan A, Lunsford LD

Abstract
Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of stereotactic radiosurgery (SRS). Our objective was to provide guidelines about the use of SRS in symptomatic patients with imaging-identified DAVFs of the brain. The authors reviewed evidence-based medicine and clinical experience with radiosurgery for DAVFs of the brain and developed guidelines and provided a scientific foundation for patients and physicians. Major recommendations include the definition of DAVF patients suitable for various management strategies ranging from observation to surgical excision to endovascular embolization and SRS. Combined SRS and embolization is an effective management strategy for DAVFs, including those that have recurred after initial embolization. The effect of prior embolization has been evaluated. SRS before embolization facilitates the better recognition of the entire target. For selected DAVF patients who are not eligible for embolization or surgery, SRS alone is an effective treatment option. The dose range for DAVFs is similar to that of arteriovenous malformations. A clinical algorithm for the potential role of SRS for a symptomatic brain DAVF was defined. These guidelines provide a framework for professional judgment and treatment selection alternatives for the management of DAVFs.

PMID: 23258525 [PubMed - in process]

Stereotactic radiosurgery guidelines for the management of patients with intracranial cavernous malformations.

Prog Neurol Surg. 2013;27:166-75

Authors: Niranjan A, Lunsford LD

Abstract
Treatment options for cavernous malformations (CMs) have expanded with the application of stereotactic radiosurgery. In this report, we provide guidelines about the use of stereotactic radiosurgery in CM patients who had 2 documented symptomatic hemorrhages. We reviewed the evidence-based medicine and clinical experience with radiosurgery for CM of the brain and developed guidelines and provided a scientific foundation for patients and physicians. We also reviewed the controversy surrounding CM radiosurgery and discussed its origin and validity. Our recommendations include the selection of CM patients suitable for various management strategies ranging from observation to surgical excision and stereotactic radiosurgery. Radiosurgery is an effective management strategy that reduces the risk of additional hemorrhages from CMs that repeatedly bleed. The marginal dose ranges from 12 to 18 Gy (median 16 Gy). A clinical algorithm for the potential role of stereotactic radiosurgery for CM patients with 2 or more symptomatic hemorrhages is defined. These guidelines provide a framework for professional judgment and assessment of management alternatives for selected intracranial CMs.

PMID: 23258521 [PubMed - in process]

Stereotactic radiosurgery guideline for the management of patients with intracranial arteriovenous malformations.

Prog Neurol Surg. 2013;27:130-40

Authors: Niranjan A, Lunsford LD

Abstract
Our objective was to provide guidelines about the use of stereotactic radiosurgery in symptomatic patients with imaging-identified arteriovenous malformations (AVMs) of the brain. We reviewed evidence-based medicine and clinical experience with radiosurgery for AVM of the brain to develop guidelines and provide scientific foundation for patients and physicians. Major recommendations include the definition of AVM patients suitable for various management strategies ranging from observation to surgical excision to endovascular embolization and stereotactic radiosurgery. The optimal dose range for volumetric conformal AVM stereotactic radiosurgery has been largely established based on location and volume of the AVM. The relationship to prior embolization or prior surgery has been evaluated. The role of repeat radiosurgery has been assessed for those patients with incomplete obliteration of their AVM after 3 years have elapsed. The causes of failure of stereotactic radiosurgery have also been identified. A clinical algorithm for the potential role of stereotactic radiosurgery for a symptomatic brain AVM was defined. The guidelines provide a framework for professional judgment and treatment selection alternatives.

PMID: 23258517 [PubMed - in process]

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines].

G Ital Cardiol (Rome). 2013 Jan;14(1):66-75

Authors: Scorcu G, Meloni L, Pilleri A, Loi B, Pirisi R, Sanna F, Cadeddu M, Serra E, Sori P, Boscarelli D, Iasiello G, Pinna G, Porcu M

Abstract
Background. An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari.Methods. From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group).Results. Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01).Conclusions. Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

PMID: 23258206 [PubMed - in process]

Guideline on the requirements of external quality assessment programs in molecular pathology.

Related Articles

Virchows Arch. 2013 Jan;462(1):27-37

Authors: van Krieken JH, Normanno N, Blackhall F, Boone E, Botti G, Carneiro F, Celik I, Ciardiello F, Cree IA, Deans ZC, Edsjö A, Groenen PJ, Kamarainen O, Kreipe HH, Ligtenberg MJ, Marchetti A, Murray S, Opdam FJ, Patterson SD, Patton S, Pinto C, Rouleau E, Schuuring E, Sterck S, Taron M, Tejpar S, Timens W, Thunnissen E, van de Ven PM, Siebers AG, Dequeker E

Abstract
Molecular pathology is an integral part of daily diagnostic pathology and used for classification of tumors, for prediction of prognosis and response to therapy, and to support treatment decisions. For these reasons, analyses in molecular pathology must be highly reliable and hence external quality assessment (EQA) programs are called for. Several EQA programs exist to which laboratories can subscribe, but they vary in scope, number of subscribers, and execution. The guideline presented in this paper has been developed with the purpose to harmonize EQA in molecular pathology. It presents recommendations on how an EQA program should be organized, provides criteria for a reference laboratory, proposes requirements for EQA test samples, and defines the number of samples needed for an EQA program. Furthermore, a system for scoring of the results is proposed as well as measures to be taken for poorly performing laboratories. Proposals are made regarding the content requirements of an EQA report and how its results should be communicated. Finally, the need for an EQA database and a participant manual are elaborated. It is the intention of this guideline to improve EQA for molecular pathology in order to provide more reliable molecular analyses as well as optimal information regarding patient selection for treatment.

PMID: 23250354 [PubMed - in process]

SAGES evidence-based guidelines for the laparoscopic resection of curable colon and rectal cancer.

Related Articles

Surg Endosc. 2013 Jan;27(1):1-10

Authors: Zerey M, Hawver LM, Awad Z, Stefanidis D, Richardson W, Fanelli RD, Members of the SAGES Guidelines Committee

PMID: 23239291 [PubMed - in process]

Implementation of Clinical Practice Guidelines for Ventilator-Associated Pneumonia: A Multicenter Prospective Study*

Related Articles

Crit Care Med. 2013 Jan;41(1):15-23

Authors: Sinuff T, Muscedere J, Cook DJ, Dodek PM, Anderson W, Keenan SP, Wood G, Tan R, Haupt MT, Miletin M, Bouali R, Jiang X, Day AG, Overvelde J, Heyland DK, Canadian Critical Care Trials Group

Abstract
OBJECTIVE:: Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN:: Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING:: Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS:: At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION:: Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS:: The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS:: A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

PMID: 23222254 [PubMed - as supplied by publisher]

Field-testing of guidance on the appropriate labelling of processed complementary foods for infants and young children in South Africa.

Related Articles

Matern Child Nutr. 2013 Jan;9 Suppl 1:12-34

Authors: Sweet L, Jerling J, Van Graan A

Abstract
There is a lack of formal guidance from international normative bodies on the appropriate marketing of processed complementary foods. Such guidance is necessary to protect and promote optimal infant and young child feeding practices. The aim of this study was to field-test, in South Africa, the interim guidance provided by the Maternal, Infant and Young Child Nutrition Working Group's Draft Guide for Marketing Complementary Foods as a potential tool for use by manufacturers and national governments for guiding the appropriate labelling (as a subset of appropriate marketing practices) of complementary foods. This guidance was used to develop a checklist of questions and criteria for each possible answer, which was tested using a comprehensive database of labels from products purchased in South Africa from June to August 2011. One hundred and sixty product labels of 35 manufacturers were analysed, none of which complied with all checklist criteria. Fifty-six (35%) labels did not provide an appropriate age of introduction while 37 (23%) used images of infants appearing younger than 6 months. Nineteen (12%) labels suggested a daily ration too large for a breastfed child, and 32 (20%) potentially promote the manufacturer's infant formula. Only 58 (36%) labels were easy to read. The majority (69% and 92%) of labels provided instructions for safe and appropriate preparation/use and storage, respectively. The Draft Guide for Marketing Complementary Foods was found to be a useful tool for guiding the appropriate labelling of complementary foods, although some changes and additions are recommended to improve understanding, ease of use and to minimise the subjective interpretation of the guidance.

PMID: 23167582 [PubMed - indexed for MEDLINE]

Experience with the European quality assurance guidelines for digital mammography systems in anational screening programme.

Related Articles

Radiat Prot Dosimetry. 2013;153(2):223-6

Authors: McCullagh J, Keavey E, Egan G, Phelan N

Abstract
The transition to a fully digital breast screening programme, utilising three different full-field digital mammography (FFDM) systems has presented many challenges to the implementation of the European guidelines for physico-technical quality assurance (QA) testing. An analysis of the QA results collected from the FFDM systems in the screening programme over a 2-y period indicates that the three different systems have similar QA performances. Generally, the same tests were failed by all systems and failure rates were low. The findings provide some assurance that the QA guidelines are being correctly implemented. They also suggest that there is more scope for the development of the relevance of the guidelines with respect to modern FFDM systems. This study has also shown that a summary review of the QA data can be achieved by simple organisation of the QA data storage and by automation of data query and retrieval using commonly available software.

PMID: 23173219 [PubMed - in process]

Guidelines for newborn screening of primary immunodeficiency diseases.

Related Articles

Curr Opin Hematol. 2013 Jan;20(1):48-54

Authors: Borte S, von Döbeln U, Hammarström L

Abstract
PURPOSE OF REVIEW: Technical possibilities to screen for inborn errors of immune function at the neonatal stage have been rapidly progressing, whereas the guidelines that apply for the evaluation of benefits and concerns on expanding screening panels have not been broadly discussed for primary immunodeficiency diseases (PID). This review reflects on the assessment of severe combined immunodeficiencies (SCID), primary agammaglobulinaemias (such as X-linked agammaglobulinaemia) and inherited haemophagocytic syndromes (such as familial haemophagocytic lymphohistiocytosis) to be included in newborn screening (NBS) programmes.
RECENT FINDINGS: Screening programmes in several federal states in the United States have been supplemented with the T-cell receptor excision circle assay during the past few years to identify children with SCID. The reported experience indicates that an efficient and validated screening approach for SCID is feasible on a population-based scale.
SUMMARY: In the light of recent advances, severe PID ought to be discussed for their rapid implementation in national NBS programmes based upon clinical, social and economical criteria as consolidated in the extended 22-item Wilson-Jungner framework. Although SCID currently most favourably fulfils these screening guidelines, other strong candidates can be identified among primary immunodeficiency disorders. Future efforts of healthcare professionals and policy makers are essential to improve the concept of neonatal screening for PID.

PMID: 23108220 [PubMed - in process]

Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan.

Related Articles

J Gastroenterol. 2013 Jan;48(1):31-72

Authors: Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T, On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology

Abstract
Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.

PMID: 23090001 [PubMed - as supplied by publisher]

Unidentified candidates for cardiac resynchronization therapy: guideline adherence in a large academic outpatient clinic in the Netherlands.

Related Articles

Pacing Clin Electrophysiol. 2013 Jan;36(1):69-75

Authors: de Groot JR, Krul SP, Kroon S, Knops RE, Peters RJ, Wilde AA

Abstract
BACKGROUND: Cardiac resynchronization therapy (CRT) reduces mortality and morbidity in patients with heart failure, diminished left ventricular function, and prolonged QRS duration. We investigated adherence to the CRT guidelines and screened for unidentified CRT candidates.
METHODS: Every unique patient visiting the outpatient clinic during three months was analyzed. In patients with QRS duration ≥120 ms or a paced QRS duration ≥200 ms on the electrocardiogram (ECG), left ventricular ejection fraction (LVEF), and New York Heart Association functional class were retrieved from hospital records and compared with the institutional implantable cardioverter defibrillator/pacemaker implantation database. The appropriateness of CRT indication was studied in patients who previously received CRT.
RESULTS: QRS duration was <120 ms in 2,609 out of 3,053 patients screened. LVEF was ≤35% in 28 out of 282 patients with a QRS duration ≥120 ms or a paced QRS duration ≥200 ms. Of those, 11 patients were potential CRT candidates. During follow-up, three patients received a CRT device, two patients died, one patient improved, and one refused implantation, leaving four potential CRT candidates. Forty-six patients previously implanted with a CRT device visited the outpatient clinic, of whom 42 (91.3%) fulfilled the guideline criteria. Hence, 45 out of 49 patients (91.8%) qualifying for CRT had received CRT or were implanted during follow-up, and four (8.2%) CRT candidates were unidentified.
CONCLUSION: In a large, tertiary academic hospital, >91% of patients fulfilling guideline criteria received CRT, and 8.2% of patients were unidentified. Systematic ECG screening of every patient may prove a simple tool to detect CRT candidates who were otherwise unrecognized. (PACE 2013; 36:69-75).

PMID: 23078171 [PubMed - in process]

Concussion guidelines need to move from only expert content to also include implementation and dissemination strategies.

Related Articles

Br J Sports Med. 2013 Jan;47(1):12-4

Authors: Finch CF, McCrory P, Ewing MT, Sullivan SJ

PMID: 23060652 [PubMed - in process]

Mechanistic sediment quality guidelines based on contaminant bioavailability: Equilibrium partitioning sediment benchmarks.

Environ Toxicol Chem. 2013 Jan;32(1):102-14

Authors: Burgess RM, Berry WJ, Mount DR, Di Toro DM

Abstract
Globally, estimated costs to manage (i.e., remediate and monitor) contaminated sediments are in the billions of U.S. dollars. Biologically based approaches for assessing the contaminated sediments which pose the greatest ecological risk range from toxicity testing to benthic community analysis. In addition, chemically based sediment quality guidelines (SQGs) provide a relatively inexpensive line of evidence for supporting these assessments. The present study summarizes a mechanistic SQG based on equilibrium partitioning (EqP), which uses the dissolved concentrations of contaminants in sediment interstitial waters as a surrogate for bioavailable contaminant concentrations. The EqP-based mechanistic SQGs are called equilibrium partitioning sediment benchmarks (ESBs). Sediment concentrations less than or equal to the ESB values are not expected to result in adverse effects and benthic organisms should be protected, while sediment concentrations above the ESB values may result in adverse effects to benthic organisms. In the present study, ESB values are reported for 34 polycyclic aromatic hydrocarbon, 32 other organic contaminants, and seven metals (cadmium, chromium, copper, nickel, lead, silver, zinc). Also included is an overview of EqP theory, ESB derivation, examples of applying ESB values, and considerations when using ESBs. The ESBs are intended as a complement to existing sediment-assessment tools, to assist in determining the extent of sediment contamination, to help identify chemicals causing toxicity, and to serve as targets for pollutant loading control measures. Environ. Toxicol. Chem. 2013;32:102-114. © 2012 SETAC.

PMID: 23060276 [PubMed - in process]

Physician specialty is associated with adherence to treatment guidelines for acute otitis media in children.

Related Articles

Acta Paediatr. 2013 Jan;102(1):e29-33

Authors: Grossman Z, Silverman BG, Miron D

Abstract
AIM: To identify physician and visit characteristics affecting adherence to guidelines recommending delayed antibiotic therapy for acute otitis media (AOM).
METHODS: We used physician visit data from an Israeli health maintenance organization to identify children ages 0-15 diagnosed with AOM. We defined early antibiotic treatment as purchase, within 3 days of diagnosis, of antibiotics prescribed by the diagnosing physician. We considered the effect of physician specialty (paediatrician, otolaryngologist, and family physician), day of the week, setting (urgent care/clinic) and clinic location (peripheral/central) on the rate of early treatment.
RESULTS: Proportion of cases receiving early treatment dropped from 2002 to 2009 in cases treated by otolaryngologists (47-36%) and paediatricians (46-42%) and increased in cases treated by family physicians (43-50%). Treatment rate was higher in cases treated on weekends than on weekdays (48% vs. 44%), in urgent care as compared to clinic settings (51% vs. 44%), and in children living in peripheral as compared to central areas (52% vs. 38%).
CONCLUSIONS: Successful implementation of delayed treatment of otitis media guidelines requires addressing factors associated with increased early treatment rates.

PMID: 23057496 [PubMed - in process]

Hospital characteristics associated with maintenance or improvement of guideline-recommended lymph node evaluation for colon cancer.

Related Articles

Med Care. 2013 Jan;51(1):60-7

Authors: Parsons HM, Begun JW, McGovern PM, Tuttle TM, Kuntz KM, Virnig BA

Abstract
BACKGROUND: Over the past 20 years, surgical practice organizations have recommended the identification of ≥12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines.
RESEARCH DESIGN: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (≥12) lymph node evaluation compared with initial evaluation levels (1996-1998) using χ tests and multivariate logistic regression analysis, adjusting for patient case-mix.
RESULTS: We identified 228 hospitals that performed ≥6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance.
CONCLUSIONS: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.

PMID: 23047124 [PubMed - in process]

Guidelines for psychological evaluations in child protection matters.

Related Articles

Am Psychol. 2013 Jan;68(1):20-31

Authors:

Abstract
The problems of abused and neglected children are epidemic in our society (U.S. Department of Health and Human Services, Administration on Children, Youth, and Families, 2008) and create issues that psychologists may be called upon to address. Psychologists are positioned to contribute significantly to decision making in child protection matters. Psychological data and expertise may provide sources of information and a perspective not otherwise available to courts regarding the functioning of parties, and thus may increase the fairness of decisions by the court, state agency, or other party. such matters. These guidelines are a revision of the 1999 "Guidelines for Psychological Evaluations in Child Protection Matters" (American Psychological Association [APA], 1999). These guidelines are informed by APA's "Ethical Principles of Psychologists and Code of Conduct" ("APA Ethics Code"; APA, 2002a, 2010). (PsycINFO Database Record (c) 2013 APA, all rights reserved).

PMID: 23025746 [PubMed - in process]

Evaluation of the efficacy of the guideline on reading CT images of malignant pleural mesothelioma with reference CT films for improving the proficiency of radiologists.

Related Articles

Eur J Radiol. 2013 Jan;82(1):169-76

Authors: Zhou H, Tamura T, Kusaka Y, Suganuma N, Subhannachart P, Vijitsanguan C, Noisiri W, Hering KG, Akira M, Itoh H, Arakawa H, Ishikawa Y, Kumagai S, Kurumatani N

Abstract
PURPOSE: To assess the efficacy of the developed guideline on reading CT images of malignant pleural mesothelioma for improving radiologists' reading proficiency.
MATERIALS AND METHODS: Three radiologists independently read the CT films of 22 cases including definite mesothelioma and non-mesothelioma cases at two times before and after studying the malignant pleural mesothelioma CT Guideline. The sensitivity and specificity for mesothelioma were calculated and compared between the 1st and 2nd trials. The kappa statistics was examined for agreement with experts for mesothelioma probability and for mesothelioma features recorded by three radiologists.
RESULTS: After studying the mesothelioma CT Guideline, the sensitivity for mesothelioma shown by the three radiologists at the 2nd trial was 100%, 100% and 80%, which were higher than 80%, 85% and 60% at the 1st trial, respectively. The average kappa for agreement between radiologists and experts on dichotomized mesothelioma probability were 0.69 (good) at the 2nd trial vs. 0.38 (fair) at the 1st trial. The average kappa for the agreement with experts for each of 7 features by three radiologists were 0.52-0.80 at the 2nd trial, which were significantly higher than 0.34-0.58 at the 1st trial (Wilcoxon Signed Rank Test: P<0.01), and as to five features "unilateral pleural effusion", "nodular pleural thickening", "tumoral encasement of lung", "mediastinal pleural thickening", and "diminished lung", they achieved good agreement with average kappa of 0.61-0.80.
CONCLUSION: The developed mesothelioma CT Guideline was suggested to have substantial effect in improving the radiologists' proficiency for reading CT images of mesothelioma, and may contribute to accurate diagnosis of mesothelioma.

PMID: 23017190 [PubMed - in process]

Remarkable differences between three evidence-based guidelines on management of obstructive sleep apnea-hypopnea syndrome.

Related Articles

Laryngoscope. 2013 Jan;123(1):283-91

Authors: Aarts MC, van der Heijden GJ, Rovers MM, Grolman W

Abstract
OBJECTIVES/HYPOTHESIS: The aim of this study was to compare available guidelines for the diagnosis and treatment of patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) regarding their content, conclusions on the available evidence, and recommendations.
STUDY DESIGN: Literature review/systematic review.
METHODS: We retrieved guidelines from Embase, PubMed, Web of Science, and Web sites of several health care improvement centers and with a Google Scholar search. We appraised the quality of selected guidelines according to the Appraisal of Guidelines for Research and Evaluation instrument. For similar clinical questions we compared the conclusions, the attached levels of evidence, and the references used. If differences were found, we checked search strategies, appraisal criteria, and publication date as possible sources for these differences.
RESULTS: We selected the guidelines on diagnosis and treatment of OSAHS of the Scottish Scottish Intercollegiate Guidelines Network, the Dutch Institute for Healthcare Improvement, and the Institute for Clinical Systems Improvement in the United States for this comparison. For similar clinical questions these three guidelines showed conflicting conclusions (11%-18%), differences in attached levels of evidence (32%-62%), and remarkable discrepancies in cited studies. A plausible reason for these differences is the citation preference for articles from members of the guidelines workgroup and from their own country. Despite different publication dates, more recent guidelines fail to cite earlier published guidelines.
CONCLUSIONS: Despite the generally accepted approach regarding the development of evidence-based guidelines, remarkable differences exist between guidelines from different countries on the same clinical subject. Laryngoscope, 2013.

PMID: 22990949 [PubMed - in process]

Evaluation of the blood compatibility of materials, cells, and tissues: basic concepts, test models, and practical guidelines.

Related Articles

Adv Exp Med Biol. 2013;734:257-70

Authors: Ekdahl KN, Hong J, Hamad OA, Larsson R, Nilsson B

Abstract
Medicine today uses a wide range of biomaterials, most of which make contact with blood permanently or transiently upon implantation. Contact between blood and nonbiological materials or cells or tissue of nonhematologic origin initiates activation of the cascade systems (complement, contact activation/coagulation) of the blood, which induces platelet and leukocyte activation.Although substantial progress regarding biocompatibility has been made, many materials and medical treatment procedures are still associated with severe side effects. Therefore, there is a great need for adequate models and guidelines for evaluating the blood compatibility of biomaterials. Due to the substantial amount of cross talk between the different cascade systems and cell populations in the blood, it is advisable to use an intact system for evaluation.Here, we describe three such in vitro models for the evaluation of the biocompatibility of materials and therapeutic cells and tissues. The use of different anticoagulants and specific inhibitors in order to be able to dissect interactions between the different cascade systems and cells of the blood is discussed. In addition, we describe two clinically relevant medical treatment modalities, the integration of titanium implants and transplantation of islets of Langerhans to patients with type 1 diabetes, whose mechanisms of action we have addressed using these in vitro models.

PMID: 22990709 [PubMed - in process]

Impact of Changes in Anti-doping Regulations (WADA Guidelines) on Asthma Care in Athletes.

Related Articles

Clin J Sport Med. 2013 Jan;23(1):74-6

Authors: Couto M, Horta L, Delgado L, Capão-Filipe M, Moreira A

Abstract
OBJECTIVE: : To investigate how changes to the World Anti-Doping Agency (WADA) guidelines on asthma medication requests have impacted the management of asthmatic athletes in Portugal.
DESIGN: : Retrospective analysis of asthma medication requests submitted in 2008 to 2010.
SETTING: : Portuguese Anti-Doping Authority database.
PARTICIPANTS: : Athletes requesting the use of inhaled corticosteroids and/or β2-agonists.
INDEPENDENT VARIABLES: : Demographic, therapeutic, and diagnostic test data.
MAIN OUTCOME MEASURES: : Yearly changes in number of asthma medication requests and diagnostic procedures.
RESULTS: : We analyzed 326 requests: 173 abbreviated Therapeutic Use Exemptions (TUEs) in 2008 (objective tests not required), 9 Declaration of Use (DoU) and 76 TUEs in 2009, and 39 DoU and 29 TUEs in 2010. Spirometry was performed in 87% and 37% of athletes in 2009 and 2010, respectively; the corresponding figures for bronchoprovocation were 59% and 16%, almost all positive in both years.
CONCLUSIONS: : Applications for inhaler use have decreased by approximately half since objective asthma testing became mandatory. Our findings show that WADA guidelines have an impact on asthmatic athletes care: In 2009 a more rigorous screening was possible, leading to withdrawal of unnecessary medication. Constant changes, however, jeopardize this achievement and nowadays introduce safety issues stemming from the unsupervised use of inhaled β2-agonists.

PMID: 22948449 [PubMed - in process]

Effect of ASCO/CAP Guidelines for Determining ER Status on Molecular Subtype.

Related Articles

Ann Surg Oncol. 2013 Jan;20(1):87-93

Authors: Deyarmin B, Kane JL, Valente AL, van Laar R, Gallagher C, Shriver CD, Ellsworth RE

Abstract
BACKGROUND: Determination of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status is standard for predicting prognosis and determining treatment options for patients with breast cancer. In 2010, the American Society of Clinical Oncology (ASCO) and College of American Pathologists (CAP) issued guidelines that tumors with ≥1 % positively staining cells should be considered ER positive. Here, we determined how this cutoff relates to molecular subtype.
METHODS: Clinicopathological characteristics were compared between ER-negative, ER-positive, and low-ER-staining (1-10 %) tumors using chi-square analysis with P < 0.05 defining statistical significance. Gene expression data were generated for 26 low-ER-staining tumors, and their intrinsic subtype determined. Immunohistochemistry (IHC)-defined surrogate subtypes, using the threshold of positivity defined by ASCO/CAP guidelines, were compared with molecular subtypes.
RESULTS: Low-ER-staining tumors were clinicopathologically more similar to ER-negative than to ER-positive tumors; 88 % of low-staining tumors were basal like or HER2 enriched. Only those tumors expressing 10 % ER-positive cells were classified as luminal A subtype.
CONCLUSIONS: Under ASCO/CAP guidelines, tumors with 1-10 % ER staining would be classified as ER positive, yet most are basal like or HER2 enriched and have pathological features similar to ER-negative tumors. Clinical trials seeking to treat tumors of ER-negative basal-like and/or HER2-enriched subtypes should thus not preclude enrollment based solely on results of ER immunohistochemistry. As ER status is a critical element in the choice of treatments for patients with breast cancer, it is imperative that the most effective method for classifying tumors be developed.

PMID: 22875649 [PubMed - in process]

Assessing stroke patients for rehabilitation during the acute hospitalization: findings from the get with the guidelines-stroke program.

Related Articles

Arch Phys Med Rehabil. 2013 Jan;94(1):38-45

Authors: Prvu Bettger JA, Kaltenbach L, Reeves MJ, Smith EE, Fonarow GC, Schwamm LH, Peterson ED

Abstract
OBJECTIVE: To examine the frequency and determinants of an assessment for rehabilitation during the hospitalization for acute stroke.
DESIGN: Prospective cohort of patients admitted with acute stroke in the Get With The Guidelines-Stroke (GWTG-Stroke) program from January 8, 2008, to March 31, 2011.
SETTING: Acute hospitals (n=1532) in the United States participating in the GWTG-Stroke program.
PARTICIPANTS: Adults with a stroke diagnosis (N=616,982) from a GWTG-Stroke-participating acute hospital.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURE: Documentation of an assessment for rehabilitation services during the acute hospitalization.
RESULTS: Overall, almost 90% of stroke patients had documentation of an acute assessment for rehabilitation. In multivariable analysis, patients significantly more likely to be assessed for rehabilitation were younger, male, black or of other nonwhite races (Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) when compared with white, independently ambulating before admission, and admitted from the community. Patients who received a stroke consult, cared for in a stroke unit, and treated in the northeast region of the United States were also more likely to be assessed.
CONCLUSIONS: There is evidence that rehabilitation was considered for 90% of acute stroke patients in this sample. Future research is needed to examine what assessments are conducted and by whom, and how these are used to determine the appropriate level of rehabilitation care for their needs.

PMID: 22858797 [PubMed - in process]

Guidelines for extended lymphadenectomy in gastric cancer: a prospective comparative study.

Related Articles

Ann Surg Oncol. 2013 Jan;20(1):218-25

Authors: Asoglu O, Matlim T, Kurt A, Onder SY, Kunduz E, Karanlik H, Sam B, Kapran Y, Bugra D

Abstract
AIMS: To assess the efficacy of extended lymph node dissection in gastric cancer and to identify factors affecting lymph node detection.
METHODS: A prospective study of 126 gastric cancer patients was conducted. Patients eligible for curative resection received total gastrectomy and extended lymphadenectomy (D2) and paraaortic lymph node sampling as the standard of care (study group). Supramesocolic total lymphadenectomy of the upper gastrointestinal tract was performed on 23 autopsy cases as a control group.
RESULTS: Fifty-five gastric carcinoma patients were included in the study group. Median age was 58 years (range 31-80 years); 14 patients were female (25 %), and 41 were male (75 %). The median number of lymph nodes harvested from the specimen was 47 (24-95), and the median number of metastatic lymph nodes was 15 (1-71). In contrast, in the autopsy comparative group, the median number of harvested lymph nodes was 72 (50-91). The median number of stational lymph nodes excised (lymph nodes excised from stations 4, 5, 10, 11, 12, and 16) was significantly higher in the control group than in the study group (P < 0.05). Lymph node detection was adversely affected by body mass index (BMI) (P < 0.03). In the study group, stations 5, 12, 11, and 10 had the highest lymph node absence (LNA) (noncompliance) ratio with percentages of 53, 36, 33, and 22 %, respectively. In the autopsy group, LNA (noncompliance) was not detected.
CONCLUSIONS: Lymph nodes should be dissected by surgeons with sufficient technical and anatomical experience, and then examined and counted by experienced pathologists to reduce the occurrence of LNA. The results of this anatomical study can serve as a guideline to assess the success of lymph node dissection during gastric cancer surgery. Similar studies should be conducted in every country to establish national guidelines.

PMID: 22851047 [PubMed - in process]

Reporting and Grading of Complications After Urologic Surgical Procedures: An ad hoc EAU Guidelines Panel Assessment and Recommendations.

Related Articles

Actas Urol Esp. 2013 Jan;37(1):1-11

Authors: Mitropoulos D, Artibani W, Graefen M, Remzi M, Rouprêt M, Truss M

Abstract
CONTEXT: The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology. OBJECTIVE: To review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes. EVIDENCE ACQUISITION: Standardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999-2000 and 2009-2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms. EVIDENCE SYNTHESIS: The systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%). CONCLUSIONS: Uniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.

PMID: 22824080 [PubMed - as supplied by publisher]

Current termination of resuscitation (TOR) guidelines predict neurologically favorable outcome in Japan.

Related Articles

Resuscitation. 2013 Jan;84(1):54-9

Authors: Kajino K, Kitamura T, Iwami T, Daya M, Ong ME, Hiraide A, Shimazu T, Kishi M, Yamayoshi S

Abstract
BACKGROUND: It is unclear whether the basic life support (BLS) and advanced life support (ALS) pre-hospital termination of resuscitation (TOR) rules developed in North America can be applied successfully to patients with out-of-hospital cardiac arrest (OHCA) in other countries.
OBJECTIVES: To assess the performance of the BLS and ALS TOR in Japan.
METHODS: Retrospective nationwide, population-based, observational cohort study of consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2009 in Japan. The BLS TOR rule has 3 criteria whereas the ALS TOR rule includes 2 additional criteria. We extracted OHCA patients meeting all criteria for each TOR rule, and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying OHCA patients who did not have neurologically favorable one-month survival.
RESULTS: During the study-period, 151,152 cases were available to evaluate the BLS TOR rule, and 137,986 cases to evaluate the ALS TOR rule. Of 113,140 patients that satisfied all three criteria for the BLS TOR rule, 193 (0.2%) had a neurologically favorable one-month survival. The specificity of BLS TOR rule was 0.968 (95% CI: 0.963-0.972), and the PPV was 0.998 (95% CI: 0.998-0.999) for predicting lack of neurologically favorable one-month survival. Of 41,030 patients that satisfied all five criteria for the ALS TOR rule, just 37 (0.1%) had a neurologically favorable one-month survival. The specificity of ALS TOR rule was 0.981 (95% CI: 0.973-0.986), and the PPV was 0.999 (95% CI: 0.998-0.999) for predicting lack of neurologically favorable one-month survival.
CONCLUSIONS: The prehospital BLS and ALS TOR rules performed well in Japan with high specificity and PPV for predicting lack of neurologically favorable one-month survival in Japan. However, the specificity and PPV were not 1000 and we have to develop more specific TOR rules.

PMID: 22705831 [PubMed - in process]

Adherence to practice guidelines for atypical glandular cells on cervical cytology.

Related Articles

Cancer Cytopathol. 2013 Jan;121(1):47-53

Authors: Sharpless KE, King CR, Schnatz PF

Abstract
BACKGROUND: Atypical glandular cells (AGC) on cervical cytology are high-risk, requiring an extensive evaluation. Compliance with practice guidelines for AGC, however, has been low. Some AGC cytology reports contain cytopathologist recommendations for evaluation. This study determines whether evaluation rates for AGC have improved over time, and whether cytopathologists' recommendations correlate with the types of evaluation women receive.
METHODS: Evaluation rates from 284 women with AGC (2004-2007) were compared with findings from 1998-2001. Rates of evaluations were compared based on cytology report recommendations.
RESULTS: A total of 76.1% of the AGC cases had histologic sampling, and 58.8% had a comprehensive evaluation. These rates are higher than those from 1998-2001 (63.5% and 35.8%, respectively; P<.01). Rates of evaluations of women with AGC "favor neoplasia" did not increase between the 2 time periods. Between 2004-2005 and 2006-2007, rates of comprehensive initial evaluations and endometrial sampling in women ≥35 years of age did not increase. Of the AGC reports that did contain cytopathologist recommendations, 28% were consistent with practice guidelines, 26% recommended an incomplete histologic evaluation, and 46% recommended repeat cytology. Women whose AGC report recommended a comprehensive evaluation or any histologic evaluation were more likely to have a comprehensive work-up (79%) than those whose reports did not contain recommendations (55%, P <0.01) or recommended repeat cytology (51%, P<0.02).
CONCLUSIONS: Adherence to practice guidelines for the evaluation of women with AGC has improved but continues to be suboptimal. Our findings suggest that continuing education and including practice guidelines on AGC cytology reports may improve compliance. Cancer (Cancer Cytopathol) 2013;121:47-53 © 2012 American Cancer Society.

PMID: 22693041 [PubMed - in process]

Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department.

Related Articles

Emerg Med J. 2013 Jan;30(1):19-23

Authors: McCanny PJ, McCoy S, Grant T, Walsh S, O'Sullivan R

Abstract
INTRODUCTION: Acute non-traumatic limp is a common reason for children to present to the emergency department (ED). There is a wide differential diagnosis for these patients, and there are certain serious conditions which cannot be missed. An evidence based guideline for the 'limping child' was designed and the impact of guideline implementation on a number of specific, predefined quantitative outcomes was assessed.
METHODS: An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared.
RESULTS: 110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (χ(2)), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (χ(2)), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (χ(2)), p=0.04). No cases of serious pathology were missed using the guideline.
CONCLUSION: Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis.

PMID: 22389351 [PubMed - in process]

Multi-centre evaluation of a phenotypic extended spectrum β-lactamase detection guideline in the routine setting.

Related Articles

Clin Microbiol Infect. 2013 Jan;19(1):70-76

Authors: Platteel TN, Cohen Stuart JW, de Neeling AJ, Voets GM, Scharringa J, van de Sande N, Fluit AC, Bonten MJ, Leverstein-van Hall MA, on behalf of the ESBL national surveillance working group

Abstract
This study aimed to evaluate the routine setting performance of a guideline for phenotypic detection of extended spectrum β-lactamases (ESBLs) in Enterobacteriaceae, recommending ESBL confirmation with Etest or combination disc for isolates with a positive ESBL screen test (i.e. cefotaxime and/or ceftazidime MIC >1 mg/L or an automated system ESBL warning). Twenty laboratories submitted 443 Enterobacteriaceae with a positive ESBL screen test and their confirmation test result (74%Escherichia coli, 12%Enterobacter cloacae, 8%Klebsiella pneumoniae, 3%Proteus mirabilis, 2%Klebsiella oxytoca). Presence of ESBL genes was used as reference test. Accuracy of local phenotypic ESBL detection was 88%. The positive predictive value (PPV) of local screen tests was 70%, and differed per method (Vitek-2: 69%, Phoenix: 68%, disc diffusion: 92%), and species (95%K. pneumoniae-27%K. oxytoca). A low PPV (3%) was observed for isolates with automated system alarm but third-generation cephalosporin MICs <2 mg/L. Local ESBL confirmation had a PPV and negative predictive value (NPV) of 93% and 90%, respectively. Compared with centrally performed confirmation tests, 7% of local tests were misinterpreted. Combination disc was more specific than Etest (91% versus 61%). Confirmation tests were not reliable for P. mirabilis and K. oxytoca (PPV 33% and 38%, respectively, although NPVs were 100%). In conclusion, performance of Etests could be enhanced by education of technicians to improve their interpretation, by genotypic ESBL confirmation of P. mirabilis and K. oxytoca isolates with positive phenotypic ESBL confirmation, and by interpreting isolates with a positive ESBL alarm but an MIC <2 mg/L for cefotaxime and ceftazidime as ESBL-negative.

PMID: 22268620 [PubMed - as supplied by publisher]

Management of chronic spontaneous urticaria in real life - in accordance with the guidelines? A cross-sectional physician-based survey study.

Related Articles

J Eur Acad Dermatol Venereol. 2013 Jan;27(1):43-50

Authors: Weller K, Viehmann K, Bräutigam M, Krause K, Siebenhaar F, Zuberbier T, Maurer M

Abstract
Background  Recently, the updated EAACI/GA(2) LEN/EDF/WAO guidelines for urticaria have been published. Objective  To examine how chronic spontaneous urticaria (csU) patients in Germany are diagnosed and treated, and to compare the outcome to the guideline recommendations. Methods  During this cross-sectional survey study, most dermatologists, paediatricians and 5149 general practitioners in private practice in Germany were asked to participate. All physicians who agreed were requested to complete a standardized questionnaire about their diagnostic and therapeutic management of csU. Results  A total of 776 questionnaires were available for analysis. Most physicians (82%) were attempting to identify underlying causes in their csU patients, but with only limited success. More than 70% reported to check for total serum IgE and to do skin prick testing (not suggested in first line by guideline). In contrast, only 10% applied the autologous serum skin test. The most common first-line treatments were non-sedating antihistamines in standard or higher doses (as recommended). However, many physicians reported still using first generation sedating antihistamines (23%) (not recommended) or systemic steroids (18%). Experience with alternative options was low. Less than one-third of the participants reported to be familiar with the guidelines. Those who did, were found to be more likely to check for underlying causes, to be more experienced with antihistamine updosing and to be more reluctant to use sedating antihistamines or systemic steroids. Conclusion  The diagnostic and therapeutic management of csU by private practice physicians does not sufficiently comply with the guidelines. Awareness of the guidelines can lead to improved care.

PMID: 22150693 [PubMed - in process]