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Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial.

JAMA. 2009 Sep 9;302(10):1059-66

Authors: Schuetz P, Christ-Crain M, Thomann R, Falconnier C, Wolbers M, Widmer I, Neidert S, Fricker T, Blum C, Schild U, Regez K, Schoenenberger R, Henzen C, Bregenzer T, Hoess C, Krause M, Bucher HC, Zimmerli W, Mueller B,

CONTEXT: In previous smaller trials, a procalcitonin (PCT) algorithm reduced antibiotic use in patients with lower respiratory tract infections (LRTIs). OBJECTIVE: To examine whether a PCT algorithm can reduce antibiotic exposure without increasing the risk for serious adverse outcomes. DESIGN, SETTING, AND PATIENTS: A multicenter, noninferiority, randomized controlled trial in emergency departments of 6 tertiary care hospitals in Switzerland with an open intervention of 1359 patients with mostly severe LRTIs randomized between October 2006 and March 2008. INTERVENTION: Patients were randomized to administration of antibiotics based on a PCT algorithm with predefined cutoff ranges for initiating or stopping antibiotics (PCT group) or according to standard guidelines (control group). Serum PCT was measured locally in each hospital and instructions were Web-based. MAIN OUTCOME MEASURES: Noninferiority of the composite adverse outcomes of death, intensive care unit admission, disease-specific complications, or recurrent infection requiring antibiotic treatment within 30 days, with a predefined noninferiority boundary of 7.5%; and antibiotic exposure and adverse effects from antibiotics. RESULTS: The rate of overall adverse outcomes was similar in the PCT and control groups (15.4% [n = 103] vs 18.9% [n = 130]; difference, -3.5%; 95% CI, -7.6% to 0.4%). The mean duration of antibiotics exposure in the PCT vs control groups was lower in all patients (5.7 vs 8.7 days; relative change, -34.8%; 95% CI, -40.3% to -28.7%) and in the subgroups of patients with community-acquired pneumonia (n = 925, 7.2 vs 10.7 days; -32.4%; 95% CI, -37.6% to -26.9%), exacerbation of chronic obstructive pulmonary disease (n = 228, 2.5 vs 5.1 days; -50.4%; 95% CI, -64.0% to -34.0%), and acute bronchitis (n = 151, 1.0 vs 2.8 days; -65.0%; 95% CI, -84.7% to -37.5%). Antibiotic-associated adverse effects were less frequent in the PCT group (19.8% [n = 133] vs 28.1% [n = 193]; difference, -8.2%; 95% CI, -12.7% to -3.7%). CONCLUSION: In patients with LRTIs, a strategy of PCT guidance compared with standard guidelines resulted in similar rates of adverse outcomes, as well as lower rates of antibiotic exposure and antibiotic-associated adverse effects. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN95122877.

PMID: 19738090 [PubMed - indexed for MEDLINE]

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The attitude of Belgian social insurance physicians towards evidence-based practice and clinical practice guidelines.

BMC Fam Pract. 2009;10:64

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

BACKGROUND: Evidence-based medicine has broadened its scope and is starting to reach insurance medicine. Although still in its initial stages, physicians in the area of insurance medicine should keep up-to-date with the evidence on various diseases in order to correctly assess disability and to give appropriate advice about health care reimbursement. In order to explore future opportunities of evidence-based medicine to improve daily insurance medicine, there is a need for qualitative studies to better understand insurance physicians' perceptions of EBM. The present study was designed to identify the attitude of insurance physicians towards evidence-based medicine and clinical practice guidelines, and to determine their ability to access, retrieve and appraise the health evidence and the barriers for applying evidence to practice. METHODS: A cross-sectional survey study was carried out among all Dutch-speaking insurance physicians employed at one of the six Belgian social insurance sickness funds and at the National Institute of Disability and Health care Insurance (n = 224). Chi-square tests were used to compare nominal and ordinal variables. Student's t-tests, ANOVA, Mann-Whitney and Kruskal-Wallis were used to compare means of continuous variables for different groups. RESULTS: The response rate was 48.7%. The majority of respondents were positive towards evidence-based medicine and clinical practice guidelines. Their knowledge of EBM was rather poor. Perceived barriers for applying evidence to practice were mainly time and lack of EBM skills. CONCLUSION: Although the majority of physicians were positive towards EBM and welcomed more guidelines, the use of evidence and clinical practice guidelines in insurance medicine is low at present. It is in the first place important to eradicate the perceived inertia which limits the use of EBM and to further investigate the EBM principles in the context of insurance medicine. Available high-quality evidence-based resources (at the moment mainly originating from other medical fields) need to be structured in a way that is useful for insurance physicians and global access to this information needs to be ensured.

PMID: 19740436 [PubMed - indexed for MEDLINE]

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Assessing the onset of pre-eclampsia in the hospital day unit: summary of the pre-eclampsia guideline (PRECOG II).

BMJ. 2009;339:b3129

Authors: Milne F, Redman C, Walker J, Baker P, Black R, Blincowe J, Cooper C, Fletcher G, Jokinen M, Moran PA, Nelson-Piercy C, Robson S, Shennan A, Tuffnell A, Waugh J,

PMID: 19740933 [PubMed - indexed for MEDLINE]

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Radiofrequency neurotomy for a patient with deep brain stimulators: proposed safety guidelines.

Pain Med. 2009 Sep;10(6):1046-9

Authors: Osborne MD

OBJECTIVE: To discuss the potential risks inherent to performing radiofrequency procedures in patients with deep brain neurostimulators, and to propose safety guidelines. DESIGN: Case report. SETTING: Tertiary care teaching hospital. SUBJECT: A 67-year-old male with intractable back pain due to advanced lumbar spondylosis, with a history of advanced Parkinson's Disease requiring two deep brain stimulators. INTERVENTION: Radiofrequency neurotomy lumbar facet joints. RESULTS: No atypical symptoms were reported during the procedure that would indicate iatrogenic injury from radiofrequency effect on the deep brain neurostimulators. The subject's back pain was relieved by 70% for greater than 6 months bilaterally. DISCUSSION: There are several theoretical concerns when using radiofrequency therapies on patients with neurostimulators. Our patient did not experience any known adverse events during or subsequent to the procedure. This article presents our proposed safety guidelines for using radiofrequency neurotomy on patients with deep brain stimulators. CONCLUSIONS: Radiofrequency medial branch neurotomy was performed on a patient with two deep brain stimulators with a satisfactory clinical outcome, and no adverse sequelae. Additional study is warranted regarding the safety and compatibility of brain neurostimulators and radiofrequency interventions.

PMID: 19744216 [PubMed - in process]

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A before-after implementation trial of smoking cessation guidelines in hospitalized veterans.

Implement Sci. 2009;4:58

Authors: Katz D, Vander Weg M, Fu S, Prochazka A, Grant K, Buchanan L, Tinkelman D, Reisinger HS, Brooks J, Hillis SL, Joseph A, Titler M

ABSTRACT: BACKGROUND: Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation. SPECIFIC OBJECTIVES: The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention. DESIGN: Pre-post study design in four VA hospitals PARTICIPANTS: Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day. INTERVENTION: The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units. OUTCOMES: The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period. TRIAL NUMBER: NCT00816036.

PMID: 19744339 [PubMed - in process]

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Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

J Pediatr Gastroenterol Nutr. 2009 Sep 9;

Authors: Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG, ,

OBJECTIVE:: To develop a North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS:: An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies and developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through Nominal Group Technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS:: More than 600 articles were reviewed for this work. The document provides evidence-based guideline for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS:: This document is intended to be used in daily practice, for the development of future clinical practice guidelines, and as a basis for clinical trials.

PMID: 19745761 [PubMed - as supplied by publisher]

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Tomorrow's Doctors: an improvement if evaluated.

Lancet. 2009 Sep 12;374(9693):851

Authors:

PMID: 19748380 [PubMed - indexed for MEDLINE]

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Guidelines for the development of social marketing programmes for sun protection among adolescents and young adults.

Public Health. 2009 Sep 11;

Authors: Johnson KM, Jones SC, Iverson D

OBJECTIVES: To formulate 'best practice' guidelines for social marketing programmes for adolescents' and young adults' sun protection. STUDY DESIGN: A Delphi consensus process. METHODS: Eleven experts in sun protection and social marketing participated in a Delphi consensus process, where they were asked to provide up to 10 key points, based on their knowledge and practical experience, which they felt were most important in developing social marketing interventions for the primary prevention of skin cancer among adolescents and young adults. After reaching consensus, the evidence base for each guideline was determined and graded via the Scottish Intercollegiate Guideline Network grading system. Participants were then asked to indicate how strongly they rated the finalized 15 recommendations based on all aspects relating to their knowledge and practical opinion, as well as the research evidence, on a visual analogue scale. RESULTS: The resultant 15 guidelines offer general principles for sun protection interventions utilizing a social marketing approach. CONCLUSIONS: This method of guideline development brought the expertise of practitioners to the forefront of guideline development, whilst still utilizing established methods of evidence confirmation. It thus offers a useful method for guideline development in a public health context.

PMID: 19748644 [PubMed - as supplied by publisher]

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[Therapy of benign prostate syndrome (BPS) : Guidelines of the German Urologists (DGU).]

Urologe A. 2009 Sep 10;

Authors: Berges R, Dreikorn K, Höfner K, Madersbacher S, Michel MC, Muschter R, Oelke M, Reich O, Rulf W, Tschuschke C, Tunn U

PMID: 19756467 [PubMed - as supplied by publisher]

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[Diagnostic and differential diagnosis of benign prostate syndrome (BPS) : Guidelines of the German Urologists.]

Urologe A. 2009 Sep 9;

Authors: Berges R, Dreikorn K, Höfner K, Madersbacher S, Michel MC, Muschter R, Oelke M, Reich O, Rulf W, Tschuschke C, Tunn U

PMID: 19756468 [PubMed - as supplied by publisher]

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