Implementation of an asthma guideline for the management of childhood asthma in general practice: a randomised controlled trial.

Prim Care Respir J. 2008 Feb 14;

Authors: Hagmolen Of Ten Have W, van den Berg NJ, van der Palen J, van Aalderen WM, Bindels PJ

AIM: The aim of the study was to assess, in a randomised, controlled design, the efficacy of different strategies to improve childhood asthma management. METHOD: Three interventions directed to three groups of general practitioners were compared: Group A – dissemination of a guideline; Group B – guideline dissemination plus an educational session; Group C – guideline dissemination, educational session, plus individualised treatment advice based on airway hyperresponsiveness (AHR) and symptoms. Efficacy of the three strategies was assessed by evaluating change in AHR in 362 children after one year. RESULTS: The overall between-group effect of the severity of AHR was not significantly different (P=0.09). In Groups A and C an improvement was seen in nocturnal symptoms (P=0.02) and in Group C an improvement was seen in the prescription of inhaled corticosteroids (P=0.03). CONCLUSION: In this study, the combined implementation strategy did not show a clear improvement in the management of children with asthma in general practice.

PMID: 18274692 [PubMed - as supplied by publisher]

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Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology.

Br J Haematol. 2008 Mar;140(5):496-504

Authors: Chee YL, Crawford JC, Watson HG, Greaves M

Unselected coagulation testing is widely practiced in the process of assessing bleeding risk prior to surgery. This may delay surgery inappropriately and cause unnecessary concern in patients who are found to have ‘abnormal’ tests. In addition it is associated with a significant cost. This systematic review was performed to determine whether patient bleeding history and unselected coagulation testing predict abnormal perioperative bleeding. A literature search of Medline between 1966 and 2005 was performed to identify appropriate studies. Studies that contained enough data to allow the calculation of the predictive value and likelihood ratios of tests for perioperative bleeding were included. Nine observational studies (three prospective) were identified. The positive predictive value (0.03-0.22) and likelihood ratio (0.94-5.1) for coagulation tests indicate that they are poor predictors of bleeding. Patients undergoing surgery should have a bleeding history taken. This should include detail of previous surgery and trauma, a family history, and detail of anti-thrombotic medication. Patients with a negative bleeding history do not require routine coagulation screening prior to surgery.

PMID: 18275427 [PubMed - in process]

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Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage.

Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):12-6

Authors: Welsh A, McLintock C, Gatt S, Somerset D, Popham P, Ogle R

Recombinant activated factor VII (rFVIIa) is emerging as a novel therapy for the treatment of life or fertility-threatening post-partum haemorrhage (PPH) unresponsive to standard therapy that in some cases may prevent the need for peripartum hysterectomy. The level of evidence to date for use of rFVIIa in PPH is limited to case reports and case series with one nonrandomised study. No high-quality randomised controlled trials have been published at this stage, precluding a quality systematic review. Guidelines have been published for the use of rFVIIa in non-obstetric haemorrhage, though to date none are available for PPH. A multidisciplinary group of Australian and New Zealand clinicians from the fields of obstetrics, anaesthesia and haematology, who have both clinical experience in and/or knowledge of rFVIIa was convened by the manufacturer. This group produced an opinion and guideline based on their experience and the published international literature on the use of rFVIIa. This is intended to be used as a guideline and algorithm for the use of rFVIIa, though any use should be tailored to local practice and resources.

PMID: 18275566 [PubMed - in process]

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Clinical biochemistry guidelines in Wales: their impact on laboratory services.

Ann Clin Biochem. 2008 Jan;45(Pt 1):39-43

Authors: Griffiths KD, Duffy EJ, Oleesky DA

BACKGROUND: Evidence of significant variations in clinical biochemistry practice in Wales led to the formation of the All Wales Clinical Biochemistry Audit Group (AWCBAG) in 1993, with the aim of auditing laboratory services to ensure that they are optimally used. As part of this process, clinical guidelines are produced and circulated to all clinical biochemistry departments in Wales. The current aim of the AWCBAG is to assess the extent and impact of adoption of these guidelines across Wales. METHODS: Three surveys were despatched at intervals over a decade to all clinical biochemistry departments in Wales to investigate practice in: (1) urine albumin testing to screen for diabetic nephropathy; (2) biochemical investigation of menopausal status and the monitoring of hormone replacement therapy; (3) screening for Cushing’s syndrome. RESULTS: The results show that laboratories across Wales are generally following guideline criteria and are adapting their practice in-line with changing recommendations. CONCLUSION: The introduction of AWCBAG guidelines has been widely accepted by clinical biochemistry departments in Wales. These guidelines have led to a more efficient and effective use of laboratory services.

PMID: 18275672 [PubMed - in process]

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Assessment of the Treatment Protocol Described in the Guidelines for Trichophyton tonsurans Infection.

Nippon Ishinkin Gakkai Zasshi. 2008;49(1):27-31

Authors: Shiraki Y, Hiruma M, Sugita T, Ikeda S

Background: Infection with the anthropophilic fungus Trichophyton tonsurans has spread among members of combat sports clubs and has become a serious public health problem in Japan and other countries. Infection usually provokes only a weak inflammatory response, and treatment compliance tends to be poor. Objective: To evaluate the hairbrush method and the treatment protocol described in the guidelines for T. tonsurans infection. Method: The study subjects were 69 individuals with positive hairbrush culture from among 327 members of 12 judo clubs participating in the survey. (a) Subjects with no more than 4 colonies by the hairbrush method were treated with miconazole nitrate shampoo. (b) Subjects with 5 or more colonies were treated with (1) itraconazole at a dose of 100 mg/day for 6 weeks or at a dose of 400 mg/day for 1 week, or (2) terbinafine at a dose of 125 mg/day for 6 weeks or at a dose of 500 mg/day for 1 week. Treatment efficacy was monitored by the hairbrush method at 1.5 and 3 months after treatment. Results: Of the 46 subjects with 5 or more colonies isolated by the hairbrush method, 32 (69.6%) took itraconazole or terbinafine in compliance with their treatment schedules and were negative for T. tonsurans after treatment. Of the 23 subjects with 4 or fewer colonies, 15 (65.2%) were negative for T. tonsurans after treatment with miconazole nitrate shampoo. Conclusion: The treatment protocol seems promising, but poor compliance is a problem with the oral treatment regimens. The shampoo therapy is only partially effective, with 35% of subjects remaining positive for T. tonsurans after this therapy. In order to eradicate this disease, we have renewed the guidelines for T. tonsurans infection.

PMID: 18277048 [PubMed - in process]

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Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence.

Int Angiol. 2008 Mar;27(1):1-59

Authors: Nicolaides AN, Allegra C, Bergan J, Bradbury A, Cairols M, Carpentier P, Comerota A, Delis C, Eklof B, Fassiadis N, Georgiou N, Geroulakos G, Hoffmann U, Jantet G, Jawien A, Kakkos S, Kalodiki E, Labropoulos N, Neglen P, Pappas P, Partsch H, Perrin M, Rabe E, Ramelet AA, Vayssaira M, Ioannidou E, Taft A

PMID: 18277340 [PubMed - in process]

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Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice.

J Clin Nurs. 2008 Mar;17(5):627-36

Authors: Paquay L, Wouters R, Defloor T, Buntinx F, Debaillie R, Geys L

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross-sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6.8%. The age-, sex- and risk-standardized prevalence per regional department varied between 4.9% and 9.1%. Of the 744 subjects at risk, 33 (4.4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64.8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30.8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4.8% adherence, 76.6% no adherence and 18.6% no prevention. A proportion of 22.2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21.4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.

PMID: 18279295 [PubMed - in process]

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OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.

Osteoarthritis Cartilage. 2008 Feb;16(2):137-62

Authors: Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P

PURPOSE: To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world. METHODS: Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale. RESULTS: Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided. CONCLUSION: Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

PMID: 18279766 [PubMed - in process]

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Variations in Practice Guideline Adherence for Abnormal Cervical Cytology in a County Healthcare System.

J Gen Intern Med. 2008 Feb 20;

Authors: Singhal R, Rubenstein LV, Wang M, Lee ML, Raza A, Holschneider CH

BACKGROUND: Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology. OBJECTIVES: The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up. SUBJECTS: Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571). MEASUREMENTS: Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up. RESULTS: Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17-1.42), older patients (OR, 1.03, 95% CI, 1.02-1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01-1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p

PMID: 18286344 [PubMed - as supplied by publisher]

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Disease progression and the application of evidence-based treatment guidelines diagnose it early: a case for screening and appropriate management.

J Manag Care Pharm. 2007 Dec;13(9 Suppl D):S6-12

Authors: Manley HJ

BACKGROUND: Screening processes to identify patients who have chronic kidney disease (CKD) early in the disease allow time to manage its comorbidities and complications effectively and aggressively. The Kidney Early Evaluation Program (KEEP), sponsored by the National Kidney Foundation (NKF), is a free screening program that targets people who have diabetes, hypertension, and parents, grandparents, or siblings with diabetes, hypertension, or CKD. OBJECTIVES: To (1) introduce KEEP and its objectives and (2) review population data and progress with goals to date. SUMMARY: The KEEP goals are to raise awareness of CKD, especially in high-risk patients, provide free testing, and encourage dialogue between patients and their physicians, leading to a treatment plan. Of the 55,000 patients who have been screened through KEEP, approximately 13,000 (29%), or nearly 1 in 3 patients, have been identified as having CKD. Once a patient has been diagnosed with CKD, clinicians must address risk factors such as diabetes, hypertension, and kidney-specific diseases (e.g., glomerular diseases) that contribute to the process of renal decline. The NKF through the Kidney Disease Outcomes Quality Initiative has assembled a series of guidelines addressing dialysis adequacy, vascular access, anemia, nutrition, CKD, bone and mineral metabolism, dyslipidemia, hypertension, cardiovascular disease, and diabetes. CONCLUSION: CKD is quite common but often unrecognized and undertreated, even though rigorous guidelines for diagnosis and care have been developed. Ten areas have been identified as important for optimal care of the CKD patient. Each of these areas should be addressed and closely monitored in this population: hypertension, anemia, glucose control, lipid control, smoking cessation, aspirin prophylaxis and use of a beta-blocker post-myocardial infarction, use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, diet, exercise, and weight control.

PMID: 18177213 [PubMed - in process]

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