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Are the National Institute for Health and Clinical Excellence guidelines that promulgate active surveillance for low-risk prostate cancer justified by the available evidence?

BJU Int. 2009 Feb;103(4):554

Authors: Parker C, Graham J

PMID: 19187350 [PubMed - in process]

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Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline.

J Pain. 2009 Feb;10(2):131-46

Authors: Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK

Optimal methods to predict risk of aberrant drug-related behaviors before initiation of opioids for chronic noncancer pain and to identify aberrant behaviors after therapy is initiated are uncertain. We systematically reviewed published literature identified through searches of Ovid MEDLINE and the Cochrane databases through July 2008. Diagnostic test characteristics and accompanying confidence intervals were calculated with data extracted from the studies. Four prospective studies evaluated diagnostic accuracy of risk prediction instruments. Two higher-quality derivation studies found that high scores on the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1 and the Revised SOAPP (SOAPP-R) instruments weakly increased the likelihood for future aberrant drug-related behaviors (positive likelihood ratios [PLR], 2.90 [95% CI, 1.91 to 4.39] and 2.50 [95% CI, 1.93 to 3.24], respectively). Low scores on the SOAPP Version 1 moderately decreased the likelihood for aberrant drug-related behaviors (negative likelihood ratio [NLR], 0.13 [95% CI, 0.05 to 0.34]) and low scores on the SOAPP-R weakly decreased the likelihood (NLR, 0.29 [95% CI, 0.18 to 0.46]), but estimates are too imprecise to determine if there is a difference between these instruments. One lower-quality study found that categorization as high risk using the Opioid Risk Tool strongly increased the likelihood for future aberrant drug-related behaviors (PLR, 14.3 [95% CI, 5.35 to 38.4]) and classification as low risk strongly decreased the likelihood (PLR, 0.08 [95% CI, 0.01 to 0.62]). Nine studies evaluated monitoring instruments for identification of aberrant drug-related behaviors in patients on opioid therapy. One higher-quality derivation study found higher scores on the Current Opioid Misuse Measure (COMM) weakly increased the likelihood of current aberrant drug-related behaviors (PLR, 2.77 [95% CI, 2.06 to 3.72]) and lower scores weakly decreased the likelihood (NLR, 0.35 [95% CI, 0.24 to 0.52]). In 8 studies of other monitoring instruments, diagnostic accuracy was poor, results were difficult to interpret due to methodological shortcomings, or standard diagnostic test characteristics were not reported. Definitions for aberrant drug-related behaviors were not standardized across studies and did not account for seriousness of identified behaviors. No reliable evidence exists on accuracy of urine drug screening, pill counts, or prescription drug monitoring programs; or clinical outcomes associated with different assessment or monitoring strategies. PERSPECTIVE: Evidence on prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments may be useful, evidence is sparse and primarily based on derivation studies, and methodological shortcomings exist in all studies. Research that performs external validation, uses standardized definitions for clinically relevant aberrant drug-related behaviors, and evaluates clinical outcomes associated with different assessment and monitoring strategies is needed.

PMID: 19187890 [PubMed - in process]

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Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline.

J Pain. 2009 Feb;10(2):147-59

Authors: Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C

Chronic noncancer pain is common and use of opioids is increasing. Previously published guidelines on use of opioids for chronic noncancer pain have been based primarily on expert consensus due to lack of strong evidence. We conducted searches on Ovid MEDLINE and the Cochrane databases through July 2008 to identify studies that addressed one or more of 37 Key Questions that a multidisciplinary expert panel identified as important to be answered to generate evidence-based recommendations on the use of opioids for chronic noncancer pain. A total of 14 systematic reviews, 38 randomized trials not included in a previously published systematic review, and 13 other studies met inclusion criteria. Almost all of the randomized trials of opioids for chronic noncancer pain were short-term efficacy studies. Critical research gaps on use of opioids for chronic noncancer pain include: lack of effectiveness studies on long-term benefits and harms of opioids (including drug abuse, addiction, and diversion); insufficient evidence to draw strong conclusions about optimal approaches to risk stratification, monitoring, or initiation and titration of opioid therapy; and lack of evidence on the utility of informed consent and opioid management plans, the utility of opioid rotation, the benefits and harms specific to methadone or higher doses of opioids, and treatment of patients with chronic noncancer pain at higher risk for drug abuse or misuse. PERSPECTIVE: Currently, clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to be set to address these critical research needs if the care of patients with chronic noncancer pain is to improve.

PMID: 19187891 [PubMed - in process]

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A 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines.

Injury. 2009 Jan 31;

Authors: Harrison M

Human bite injuries are a common injury, roughly accounting for around 0.1% of attendances to Emergency Medicine departments. Morbidities associated with such injuries are legion. Of paramount importance is the potential for infection of the wound site, both bacterial and viral. A retrospective 4-year review of 3136 case notes was conducted, identifying 421 human bites. This amounts to one every 3 days! The majority of those bitten were young males (male:female ratio=3:1; 44% comprising the age group 16-25 years). The management of these wounds was found to be poor. 17% of patients did not receive any antibiotic cover; 21% of patients either did not have tetanus prophylaxis administered when required or had a tetanus booster when they were already covered; 34% of patients either did not receive a hepatitis B booster when one was required or received one when they were already covered. This lack of effective documentation, along with errors in addressing prophylaxis of the infective agents, may have profound medico-legal consequences. The author believes that the findings will be reproduced in other centres and in view of the inadequacies highlighted by this work, it is necessary to introduce an evidence-based protocol for the comprehensive management of the human bite. Using United Kingdom Department of Health evidence-based guidelines, the author proposes such a pathway.

PMID: 19187933 [PubMed - as supplied by publisher]

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Guideline provides evidence-based advice for treating osteoarthritis of the knee.

JAMA. 2009 Feb 4;301(5):475-6

Authors: Voelker R

PMID: 19190308 [PubMed - indexed for MEDLINE]

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[Autoimmune vasculitides. Standards and guidelines of EULAR and EUVAS.]

Internist (Berl). 2009 Feb 8;

Authors: Moosig F, Holle JU, Gross WL

Recently, the European League Against Rheumatism (EULAR) published recommendations on the management of patients with primary systemic vasculitides. The use of the given definitions for different activities and stages of the diseases is encouraged not only in clinical trails but also for the purpose of harmonisation in daily routine. Concerning the diagnostic work-up an interdisciplinary approach in co-operation with expert-centre is recommended. Therapy consists of remission induction and maintenance. For induction therapy in small vessel vasculitis cyclophosphamide or medium potent immunosuppressants such as methotrexate plus glucocorticoids should be used according to disease stage and activity. Glucocorticoids also represent the mainstay of remission induction in large vessel vasculitis. Additional immunosuppressants should be considered, if the disease can not be controlled by glucocorticoids or for the purpose of sparing glucocorticoids. Refractory disease should be treated within clinical trails. Further recommendations deal with monitoring of diseases activity and therapy as well as with measures to avoid complications and late sequelae.

PMID: 19198789 [PubMed - as supplied by publisher]

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Hypertension Guideline Adherence Among Nursing Home Patients.

J Gen Intern Med. 2009 Feb 7;

Authors: Drawz PE, Bocirnea C, Greer KB, Kim J, Rader F, Murray P

BACKGROUND: Adherence to hypertension guidelines in the outpatient setting is low. OBJECTIVE: To evaluate adherence to JNC VII guidelines in nursing home patients. DESIGN: Data were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. PARTICIPANTS: There were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension. MAIN RESULTS: Of these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic. CONCLUSIONS: Adherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.

PMID: 19198958 [PubMed - as supplied by publisher]

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Tackling empirical antibiotic therapy for ventilator-associated pneumonia in your ICU: guidance for implementing the guidelines.

Semin Respir Crit Care Med. 2009 Feb;30(1):102-15

Authors: Kuti JL, Shore E, Palter M, Nicolau DP

Guidelines published jointly by the American Thoracic Society and Infectious Diseases Society of America endorse the practice of appropriate empirical antibiotic therapy for ventilator-associated pneumonia (VAP) and even provide recommendations for specific antibiotics based on whether a patient has risk factors for multidrug-resistant infections. Unfortunately, the current guidelines provide little insight into how a specific institution can best develop a strategy for providing empirical antibiotic therapy. This review article focuses on important steps that should be taken in developing a hospital-specific pathway for the empirical antibiotic treatment of VAP. Consideration should be given to developing a multidisciplinary group to obtain intensive care unit (ICU)-specific antibiograms for the most common causative organisms, real-time minimum inhibitory concentration (MIC) data or MIC distributions from surveillance studies over a representable time frame, and implementing empirical dosage strategies aimed at achieving not only appropriate therapy but also optimal therapy based on pharmacodynamic targets. A proper deescalation strategy will also be vital to managing antibiotic choices and dosages, as well as providing useful recommendations for discontinuation of therapy. Finally, continued feedback of program results is critical to maintaining compliance as well as for reevaluating empirical antibiotic choices.

PMID: 19199192 [PubMed - in process]

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Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO) hepatitis C guidelines: a European Renal Best Practice (ERBP) position statement.

Nephrol Dial Transplant. 2009 Feb 8;

Authors: Covic A, Abramowicz D, Bruchfeld A, Leroux-Roels G, Samuel D, van Biesen W, Zoccali C, Zoulim F, Vanholder R,

PMID: 19202192 [PubMed - as supplied by publisher]

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Evidence, guidelines, performance incentives, complexity, and old people: a clinician's dilemma.

J Am Geriatr Soc. 2009 Feb;57(2):353-4

Authors: Larson EB

PMID: 19207151 [PubMed - in process]

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