Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world.

Europace. 2008 Apr 10;

Authors: Meiltz A, Zimmermann M, Urban P, Bloch A,

Aims The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in cardiology practice and to assess how successfully guidelines have been implemented in real-world practice. Methods and results This prospective study involved 23 cardiologists established in office practice in Geneva. Enrolment started on 1 January 2005 and ended on 31 December 2005. Consecutive patients were included if they were >18 years and had AF documented on an ECG during the index office visit or during the preceding month. In this survey, 622 ambulatory patients were enrolled (390 males and 232 females; mean age 69.8 +/- 11.8 years). The prevalence of paroxysmal, persistent, and permanent AF was 35, 18, and 47%, respectively. Underlying cardiac disorders present in 513 patients (82%) included hypertensive heart disease (30%), valvular heart disease (27%), coronary artery disease (18%), and myocardial disease (11%). A rate-control strategy was chosen in 53% of the patients (331/622). The mean CHADS(2) score was 1.43 +/- 1.24, and 458/622 patients (73.6%) had a CHADS(2) score >/=1. Among patients with an indication to oral anticoagulant therapy (OAT), 88% (403/458) effectively received it. The rate of OAT was closely correlated with an increasing CHADS(2) score, particularly with patients age (72, 81, and 87% for patients 75 years of age, respectively). True contraindication for OAT was present in 4% (18/458). In the low-risk group (CHADS(2) score = 0), 58% were prescribed OAT, but in 37% of them only for a short period of time (cardioversion/ablation). After a follow-up of 396 +/- 109 days, 72% of the study group (410/570) was still treated by OAT. During follow-up, 23/570 patients died (4%), essentially from a cardiovascular cause (15/23), 15 had a non-lethal embolic stroke (2.7%), and 8 had significant bleeding complications (1.5%). Conclusion This study shows one of the highest OAT prescription rates for AF reported until now and demonstrates how successfully guidelines can be applied in the real world. A definite overinterpretation of current guidelines is observed in low-risk patients with AF. True contraindication for OAT (4%) and significant bleeding during OAT (1.5%) were rare.

PMID: 18403385 [PubMed - as supplied by publisher]

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[Interpretation of the appropriate guideline for elective coronary angioplasty for the cases with stable angina pectoris]

Nippon Naika Gakkai Zasshi. 2008 Feb 10;97(2):453-6

Authors: Miyazaki S

PMID: 18404857 [PubMed - indexed for MEDLINE]

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Nursing Best Practice Guidelines: reflecting on the obscene rise of the void.

J Nurs Manag. 2008 May;16(4):394-403

Authors: Holmes D, Murray SJ, Perron A, McCabe J

AIM(S): Drawing on the work of Jean Baudrillard and Michel Foucault, the purpose of this article is to critique the evidence-based movement [and its derivatives - Nursing Best Practice Guidelines (NBPGs)] in vogue in all spheres of nursing. BACKGROUND: NBPGs and their correlate institutions, such as the Registered Nurses’ Association of Ontario (RNAO) and ‘spotlight’ hospitals, impede critical thinking on the part of nurses, and ultimately evacuate the social, political and ethical responsibilities that ought to distinguish the nursing profession. EVALUATION: We contend that the entire NBPG movement is based on the illusion of scientific truth and a promise of ethical care that cannot be delivered in reality. We took as a case study the Registered Nurses’ Association of Ontario (RNAO), in the province of Ontario, Canada. KEY ISSUES: NBPGs, along with the evidence-based movement upon which they are based, are a dangerous technology by which healthcare organizations seek to discipline, govern and regulate nursing work. CONCLUSION(S): Despite the remarkable institutional promotion of ‘ready-made’ and ‘ready-to-use’ guidelines, we demonstrate how the RNAO deploys BPGs as part of an ideological agenda that is scientifically, socially, politically and ethically unsound. Implications for nursing management Collaborations between health care organizations and professional organizations can become problematic when the latter dictate nursing conduct in such a way that critical thinking is impeded. We believe that nurse managers need to understand that the evidence-based movement is the target of well-deserved critiques. These critiques should also be considered before implementing so-called ‘Nursing Best Practice Guidelines’ in health care milieux.

PMID: 18405255 [PubMed - in process]

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[How can we find, design, evaluate and use clinical practice guidelines?]

Gastroenterol Hepatol. 2008 Apr;31(4):239-257

Authors: Gisbert JP, Alonso-Coello P, Piqué JM

PMID: 18405490 [PubMed - as supplied by publisher]

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Iron overload in myelodysplastic syndromes: A Canadian consensus guideline.

Leuk Res. 2008 Apr 9;

Authors: Wells RA, Leber B, Buckstein R, Lipton JH, Hasegawa W, Grewal K, Yee K, Olney HJ, Larratt L, Vickars L, Tinmouth A

In December 2005, 11 Canadian hematologists met to develop an evidence-based clinical practice guideline that would address the diagnosis, monitoring, management, and rationale for the treatment of transfusional iron overload in patients with myelodysplastic syndromes (MDS). This Expert Panel consisted of hematologists from across Canada, each with an active practice in a major population centre or a rural area. Based on an extensive literature search and years of clinical experience, their mandate was to address common clinical practice questions, particularly why treat, whom to treat, when to initiate treatment, and how to treat iron overload in patients with MDS.

PMID: 18405971 [PubMed - as supplied by publisher]

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[New guidelines for urinary stone treatment : Controversy or development?]

Urologe A. 2008 Apr 12;

Authors: Türk C, Knoll T, Köhrmann KU

The new guidelines of the European (EAU), American (AUA), German, and Austrian associations of urology are based on thorough and consistent research and analysis of the published literature. However, the methodology is very diverse. In the case of the EAU-AUA guidelines on ureteral stones, the evidence was generated by a laborious meta-analysis of the entire available published literature on the subject. These guidelines represent the 1A level of evidence. The traditional European guidelines evaluate each statement separately and assign a level of evidence to each.The following aspects are new: the even greater effort to formulate guidelines accompanied by the initiation of international cooperative projects, clarity of presentation and evaluation of the individual statements (including levels of evidence), information on medication-based treatment to facilitate spontaneous passage of ureteral stones as well as stone fragments after extracorporeal shock wave lithotripsy (ESWL), a shift in the value of ESWL and ureterorenoscopy for ureteral stones, retrograde intrarenal surgery for small kidney stones refractory to ESWL or in settings unsuitable for ESWL, the use of laparoscopy in those rare cases that represent an indication for open surgery, and the additional value given to metaphylaxis in diagnosis and therapy.All of the new guidelines take these developments into account, although they differ slightly in the importance they assign to the individual items. The modifications represent the developments secondary to electronic data processing and preparation on the one hand and the rapid development of medical instruments on the other. Although ESWL is still the most important procedure for treating urinary stones, advances in flexible endoscopes, intracorporeal lithotripsy, and extraction instruments have led to a shift in the range of indications. These developments are fully accommodated in the new guidelines.

PMID: 18408910 [PubMed - as supplied by publisher]

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Rationale for producing evidence-based guidelines for community-acquired pneumonia in the Gulf Corporation Council.

J Chemother. 2007 Oct;19 Suppl 1:13-6

Authors: Memish AZ, Ahmed QA, Arabi Y, Shibl AM, Niederman MS,

World-wide community-acquired pneumonia (CAP) is a common respiratory tract infection and is now a growing public health concern in the GCC region. Practice guidelines are derived statements which lead to informed clinical decision making. National and regional guidelines have been developed in North America, South America, South Africa and Western Europe to assist practitioners managing patients with CAP and have demonstrated to improve patients outcome. Four years have elapsed since the publication of the Saudi Arabian CAP guideline and notable changes in the area of CAP demand revision of this earlier document. We expanded previous guidelines to a regional level in a number of ways: by incorporating changes in antimicrobial resistance profiles in the region, by considering the regional availability of antibiotics and diagnostic procedures, by including emerging data on new advancements in diagnosis and treatment of CAP and, finally, by adopting an evidence-based approach in grading relevant data. The current document seeks to target primary care physicians who manage most patients with CAP in the GCC region. All available and relevant peer reviewed studies published until June 2007 were considered in the literature review. Based on the strength of the evidence, we graded our recommendations to high-level (Level I), moderate-level (Level II), and low-level (Level III) evidence.

PMID: 18073165 [PubMed - in process]

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Modelling the cost-effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK Cervical Screening Programme.

BJOG. 2008 May;115(6):749-57

Authors: Hadwin R, Eggington S, Brennan A, Walker P, Patnick J, Pilgrim H

OBJECTIVE: To evaluate the capacity implications and health economic impact of new guidelines recommending referral to colposcopy after one mild result during cervical screening rather than after two consecutive mild results. DESIGN: A mathematical model of the country’s colposcopy services and the clinical pathways from smear result through to treatment is constructed. The model incorporates national questionnaire data on referral numbers and management practices, routine data and published research results. SETTING: All English NHS colposcopy services. POPULATION: Women aged 25 to 64 years. METHODS: The national average workload impact of the change in referral guidelines is predicted, and the impact in differing local circumstances is evaluated within the model. A long-term health economic model examines the resulting costs and predicted change in quality-adjusted life years (QALYs). MAIN OUTCOME MEASURES: Colposcopy workload implications for single mild dyskaryosis referral and cost per QALY analysis. RESULTS: We found that single mild dyskaryosis referral implies, on average, a 21% increase in colposcopy workload for services not currently operating this policy. The health economic model predicted a cost per QALY gained as a result of the implementation of the new referral guidelines of around pound7,500. CONCLUSIONS: Referral after one mild result will increase workload at colposcopy; however, it may be possible to counterbalance the additional workload by altering other clinical practice. The change to referral guidelines would be considered cost-effective in comparison with many interventions routinely available on the NHS.

PMID: 18410660 [PubMed - in process]

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Preoperative beta-blocker use: impact of national guidelines on clinical practice.

J Clin Anesth. 2008 Mar;20(2):122-8

Authors: Akhtar S, Assaad S, Amin M, Holt NF, Barash PG, Silverman DG

STUDY OBJECTIVE: To determine if recommendations regarding perioperative beta-blocker therapy were followed by an increase in the number of eligible presurgical patients receiving beta-blockers and the number achieving the recommended heart rate (HR

PMID: 18410867 [PubMed - in process]

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Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2000 British Association for Psychopharmacology guidelines.

J Psychopharmacol. 2008 May 2;

Authors: Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, Matthews K, McAllister-Williams RH, Peveler RC, Scott J, Tylee A

A revision of the 2000 British Association for Psychopharmacology evidence based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

PMID: 18413657 [PubMed - as supplied by publisher]

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