Guidelines on the basic outcome data from International Association for the Study of Pain.

Clin J Pain. 2007 Jul-Aug;23(6):549

Authors: Yang Y, Chengyuan W

PMID: 17575497 [PubMed - in process]

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The Effect of Commitment to the Organization on Physicians’ Familiarity With Guidelines for Diabetes in Managed Care Organizations.

J Ambul Care Manage. 2007 July/September;30(3):231-240

Authors: Gross R, Tabenkin H, Heymann AD, Porath A, Porter B, Matzliach R, Greenstein M

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians’ practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel’s 2 largest managed care health plans. The findings indicated that “commitment to the health plan” and “perceived monitoring by the health plan” had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians’ commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.

PMID: 17581435 [PubMed - as supplied by publisher]

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Peritonitis in children who receive long-term peritoneal dialysis: a prospective evaluation of therapeutic guidelines.

J Am Soc Nephrol. 2007 Jul;18(7):2172-9

Authors: Warady BA, Feneberg R, Verrina E, Flynn JT, Müller-Wiefel DE, Besbas N, Zurowska A, Aksu N, Fischbach M, Sojo E, Donmez O, Sever L, Sirin A, Alexander SR, Schaefer F,

In children who are on chronic peritoneal dialysis, peritonitis is the primary complication compromising technique survival, and the optimal therapy of peritonitis remains uncertain. An Internet-based International Pediatric Peritonitis Registry was established in 47 pediatric centers from 14 countries to evaluate the efficacy and safety of largely opinion-based peritonitis treatment guidelines in which empiric antibiotic therapy was stratified by disease severity. Among a total of 491 episodes of nonfungal peritonitis entered into the registry, Gram-positive organisms were cultured in 44%, Gram-negative organisms were cultured in 25%, and cultures remained negative in 31% of the episodes. In vitro evaluation revealed 69% sensitivity of Gram-positive organisms to a first-generation cephalosporin and 80% sensitivity of Gram-negative organisms to a third-generation cephalosporin. Neither the risk factors assumed by the guidelines nor the choice of empiric therapy was predictive of either the early treatment response or the final functional outcome of the peritonitis episodes. Overall, 89% of cases achieved full functional recovery, a portion after relapsing peritonitis (9%). These data serve as the basis for new evidence-based guidelines. Modification of empiric therapy to include aminoglycosides should be considered.

PMID: 17582162 [PubMed - in process]

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Prolonged Emergency Department Stays of Non-ST-Segment-Elevation Myocardial Infarction Patients Are Associated With Worse Adherence to the American College of Cardiology/American Heart Association Guidelines for Management and Increased Adverse Events.

Ann Emerg Med. 2007 Jun 19;

Authors: Diercks DB, Roe MT, Chen AY, Peacock WF, Kirk JD, Pollackjr CV, Gibler WB, Smithjr SC, Ohman M, Peterson ED

STUDY OBJECTIVE: We evaluate the association of emergency department (ED) length of stay with use of guideline-recommended therapies for acute treatments and clinical outcomes. Prolonged ED stays often reflect ED crowding or limited hospital capacity. We hypothesized that patients with non-ST-segment-elevation myocardial infarction who have ED stays of greater than 8 hours may have lower quality of care and worse outcomes. METHODS: Using a secondary analysis of data from an observational registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines, CRUSADE), we compared rates of use of 5 individual acute (8 hours]). Multivariable analyses were used to determine independent association of ED length of stay with acute medications and inhospital outcomes (death and myocardial infarction). RESULTS: This analysis included 42,780 patients with non-ST-segment-elevation myocardial infarction. The median ED length of stay was 4.3 hours (25th to 75th percentile 2.9, 6.3); 15% of patients stayed longer than 8 hours. Patients who had long ED stays were more likely to be women and nonwhite and less likely to have health maintenance organization or private insurance. After adjustment, patients with long ED stays less often received guideline-recommended acute myocardial infarction therapies. Although risk-adjusted inhospital mortality rates were similar among groups, the rate of recurrent myocardial infarction increased among patients with long ED stays (odds ratio 1.23; 95% confidence interval 1.01 to 1.48) compared with those with average ED length of stay. CONCLUSION: For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. However, there was no observed difference in mortality. Factors associated with prolonged ED length of stay should be evaluated to optimize treatments and outcomes of patients with non-ST-segment-elevation myocardial infarction.

PMID: 17583379 [PubMed - as supplied by publisher]

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[Evaluation of indoor air contaminants by means of reference and guideline values.]

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007 Jul;50(7):990-1005

Authors:

Assessment of indoor air contaminants is recommended to be based on toxicologically derived guideline values (GV, German: Richtwerte, RW) for single substances, TVOC levels, and statistically derived reference values. This recommendation refers to private and public indoor environments and workplaces without production-related handling of hazardous substances. According to the working group’s current assessments, the GV I (RW I) is a concentration below which no adverse health effects are to be expected even at life-long exposure to the respective single substance. Concentrations exceeding GV II (RW II) are likely to represent a threat to health, especially for sensitive people. According to a general scheme, guideline values I and II have been derived for- toluene (0.3 and 3 mg/m(3)),- pentachlorophenol (0.1 and 1 mug/m(3)),- dichloromethane (0.2 and 2 mg/m(3)),- styrene (0.03 and 0.3 mg/m(3)),- tris(2-chloroethyl)phosphate (0.005 and 0.05 mg/m(3)),- bicyclic terpenes (0.2 and 2 mg/m(3),- naphthalene (0.002 and 0.02 mg/m(3)),- aliphatic hydrocarbons (0.2 and 2 mg/m(3)).In case of concentrations exceeding GV II, immediate measures are to be taken, among them restrictions of the time spent in the room and measures to remove or reduce emission sources. At levels between GV I and GV II, increased air exchange and cleaning are adequate first steps. However, if concentrations continue to exceed GV I, more intensive measures are recommended. Based on the TVOC concept (cf. Seifert 1990), 5 stages with specific recommendations are defined provided that the special GVs (”Richtwerte”) are not exceeded:Level 1: TVOC 0.3-1 mg/m(3): No relevant objections, but increased ventilation recommended.Level 3: TVOC > 1-3 mg/m(3): Concerning hygienic aspects, some objections due to elevated concentration level. Upper range for a maximum of 12 months. Search for sources, increased ventilation recommended.Level 4: TVOC > 3-10 mg/m(3): Major objections. Should not be tolerated for > 1 month. Restricted use only. Search for sources, intensified ventilation necessary.Level 5: TVOC > 10-25 mg/m(3): Situation not acceptable. Use only if unavoidable and then for short periods (hours) only with intensified ventilation.An assessment based on reference values does not imply any health risk assessment. It only provides information on exposure relative to the exposure of the reference group. For comparison, regularly updated and representative reference values are recommended. In case of exceeded reference values, plausibility should be checked. Considering concentration and known toxicological data, health relevance should be estimated in order to decide on the necessity of measures to be taken. Since results of indoor air measurements are strongly influenced by sampling strategy, ventilation and climatic factors, recommendations are given in order to standardise sampling procedures and conditions.

PMID: 17585378 [PubMed - in process]

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Assessing Quality and Functionality of DNA from Fresh and Archival Dried Blood Spots and Recommendations for Quality Control Guidelines.

Clin Chem. 2007 Jun 22;

Authors: Sjöholm MI, Dillner J, Carlson J

BACKGROUND: Dried blood spots (DBS) are a convenient and inexpensive method for biobanking. Although many countries have established population-based DBS biobanks from neonatal screening programs, the quality and usefulness of DNA from DBS have not been extensively assessed. METHODS: We compared 4 common DNA extraction methods (Qiagen, EZNA, Chelex 100, and alkaline lysis) in a pilot study using fresh DBS with known lymphocyte count. We assessed suitability for multiple displacement amplification (MDA) and subsequent single-nucleotide polymorphism (SNP) analyses. We selected the EZNA method for DNA extraction from archival samples up to 27 years old, stored at room temperature or -20 degrees C, and SNP analyses were performed after MDA. RESULTS: Extraction using alkaline lysis failed in most tests, and Chelex 100 was unsuccessful in real-time PCR, whereas the EZNA and Qiagen methods were successful by all evaluated quality indices. DNA extraction by EZNA, MDA, and SNP analyses were successful for the archival samples stored at -20 degrees C. CONCLUSION: Routine protocols for evaluation of the quality and functional integrity of DNA based on DNA yield, DNA size, and quantification of amplifiable DNA allow use of sufficient template for MDA and successful SNP analyses from both primary DBS extract and MDA product. A single 3-mm disc can yield sufficient DNA for several thousand SNP analyses. DNA from DBS is thus suitable for genetic epidemiology studies.

PMID: 17586590 [PubMed - as supplied by publisher]

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Evidence-based guidelines for the management of lower urinary tract symptoms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary.

Curr Med Res Opin. 2007 Jun 20;

Authors: Spatafora S, Conti G, Perachino M, Casarico A, Mazzi G, Pappagallo GL

Background and scope: Despite the high prevalence and huge socio-economic impact of benign prostatic hyperplasia (BPH) in Italy, no national guidelines have been produced so far. This is a summary of the first Italian guidelines on the diagnosis and treatment of lower urinary tract symptoms (LUTS) related to uncomplicated BPH, prepared by a multidisciplinary panel under the auspices of the Italian Association of Urologists and introduced in Italy in 2003. An update compiled by the authors is also included.METHODS: Relevant papers published from 1998 to 2003 (updated to 2006) were identified through a structured literature review and the quality of evidence presented therein was graded according to the Centre for the Evaluation of Effectiveness in Health Administration (CeVEAS) system. Recommendations were based on evidence from the literature, but also on feedback from practitioners and specialists.Main findings/recommendations: Given the prevalence of BPH, all men aged >/= 50 years of age should be asked about LUTS and informed about disease characteristics and therapeutic options, while sexual function should always be assessed in patients with severe and long-standing LUTS. Initial assessment should include medical history (including drug and co-morbidity history), digital rectal examination, urinalysis, International Prostate Symptom Score-Quality of Life (IPSS-QoL) and a voiding diary, while prostate-specific antigen (PSA) and measurement of prostate volume by suprapubic ultrasonography are indicated in fully informed patients with a life expectancy of >/= 10 years in whom BPH progression could influence treatment choices. QoL considerations should dictate whether to start active treatment. When QoL is not affected by LUTS, watchful waiting is indicated if symptoms are mild, acceptable if they are moderate. When QoL is affected, medical therapy with alpha(1)-blockers or 5alpha-reductase inhibitors (the latter indicated in patients with increased prostate volume) is appropriate. Combined therapy with alpha(1)-blockers + 5alpha-reductase inhibitors should only be considered in patients at high risk for progression (prostate volume > 40 mL or PSA > 4 ng/mL), since the incremental cost of combination therapy vs. monotherapy with alpha(1)-blockers or finasteride is prohibitive. Selection of the type of surgery should be based on the surgeons experience, the presence of co-morbid conditions and the size of the prostate. Open prostatectomy and transurethral resection of the prostate (TURP) are recommended in patients with acute or chronic retention of urine, and acceptable in obstructed patients with moderate/severe symptoms and worsened QoL. Transurethral incision of the prostate (TUIP) is acceptable when prostate volume is

PMID: 17588302 [PubMed - as supplied by publisher]

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Tracheotomy: clinical review and guidelines.

Eur J Cardiothorac Surg. 2007 Jun 22;

Authors: De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, Van Meerhaeghe A, Van Schil P

Tracheotomy is a commonly performed procedure. The Belgian Society of Pneumology (BVP-SBP) and the Belgian Association for Cardiothoracic Surgery (BACTS) developed guidelines on tracheotomy for mechanical ventilation in adults. The levels of evidence as developed by the American College of Chest Physicians (ACCP) were used. The members of the guideline committee reviewed peer-reviewed publications on this subject. After discussion, a proposal of guidelines was placed on the website for remarks and suggestions of the members. Remarks and suggestions were discussed and used to adapt the guidelines when judged necessary. The different techniques of tracheotomy are described. The potential advantages and disadvantages of surgical and percutaneous tracheotomy versus endotracheal intubation are discussed. An overview of early and late complications is given. Low-pressure, high-volume cuffs should be used. The cuff pressure should be monitored with calibrated devices and recorded at least once every nursing shift and after manipulation of the tracheotomy tubes. Inspired gas should be humidified and heated. Regarding the timing of tracheotomy there are not enough well-designed studies to establish clear guidelines. Therefore, the timing of tracheotomy should be individualised. In critically ill adult patients requiring prolonged mechanical ventilation, tracheotomy performed at an early stage (within the first week) may shorten the duration of artificial ventilation and length of stay in intensive care. Percutaneous dilatational tracheotomy (PDT) appears to be at least as safe as surgical tracheotomy (ST) as measured in terms of peri-procedural complications. With PDT, less wound infection is observed. When PDT is compared to ST performed in the operating room, PDT is less expensive, reduces the time between the decision and the performance of tracheotomy and has a lower mortality rate. Different techniques of PDT are discussed. We recommend performing PDT under bronchoscopic guidance. Because of its technical simplicity and short procedure time, the modified Ciaglia Blue Rhino technique is advocated as technique of choice. PDT should be considered the procedure of choice in elective non-urgent tracheotomy. There are some relative contraindications for PDT, but with growing experience, they become less frequent.

PMID: 17588767 [PubMed - as supplied by publisher]

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Using the European guidelines to evaluate the Norwegian Breast Cancer Screening Program.

Eur J Epidemiol. 2007 Jun 27;

Authors: Hofvind S, Geller B, Vacek PM, Thoresen S, Skaane P

This is an evaluation of selected process indicators achieved during the first 10 years of performance of the Norwegian Breast Cancer Screening Program (NBCSP). The indicators are compared with the recommended levels given in the European Guidelines. The program invites all female residents aged 50-69 years old to two-view mammography biennially. The attendance rate was 76.2%. The recall rates due to positive mammography were 4.6% and 2.6%, and the detection rates were 6.4 and 4.9 per 1,000 screens, in prevalent and subsequent screens, respectively. Mean tumor size was 14.7 mm for screening detected and 21.2 mm for interval cancers. Axillary lymph node metastases were present in 25.4% and 43.8%, respectively. Detection mode (screening detected or interval cancer) was shown to be an independent predictor for axillary lymph node metastases and high-grade (Grade 3) tumors. The NBCSP meets the recommendations given in the European Guidelines for most of the process indicators evaluated in this study. Based on the results, we anticipate a future mortality reduction from breast cancer in women invited to the NBCSP.

PMID: 17594526 [PubMed - as supplied by publisher]

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Critical Care Nurses’ Knowledge of Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia: An Evaluation Questionnaire.

Am J Crit Care. 2007 Jul;16(4):371-377

Authors: Labeau S, Vandijck DM, Claes B, Van Aken P, Blot SI,

BACKGROUND: Nurses’ lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia. OBJECTIVE: To develop a reliable and valid questionnaire for evaluating critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. METHODS: Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses. RESULTS: Face and content validity were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.10 to 0.65. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses. CONCLUSION: The questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.

PMID: 17595369 [PubMed - as supplied by publisher]

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