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Quality of care assessment and adherence to the international guidelines considering dialysis, water treatment, and protection against transmission of infections in university hospital-based dialysis units in Cairo, Egypt.

Hemodial Int. 2009 Sep 16;

Authors: Ibrahim S

Abstract End-stage renal disease has emerged as a major public health problem around the world. In recent decades, several important advances have been made in the therapy of hemodialysis (HD) with the introduction of international guidelines to ensure the delivery of optimum care to HD patients. An increased mortality risk in HD patients unable to meet six targets in different areas of HD practice has been reported by the Dialysis Outcomes and Practice Patterns Study investigators. In this retrospective study, we assessed the current practice patterns of care for HD patients in the Kaser El-Aini Nephrology and Dialysis Center in comparison with Dialysis Outcomes Quality Initiative Guidelines, European Best Practice Guidelines, Centers for Disease Control and Prevention guidelines for prevention of transmission of infections among HD patients, and American Association for Medical Instrumentation (AAMI) standards for dialysis water quality. The mean percent of urea reduction was 63 +/- 8.8% in prevalent HD patients. An arteriovenous fistula was the vascular access in 91% of prevalent HD patients, whereas a temporary catheter was used in 9% of cases mostly as a bridge till arteriovenous fistula creation/maturation. Bicarbonate was the base used in 80% of the cases. Ninty-seven percent patients had thrice-weekly sessions and 3% had two dialysis sessions/wk. The mean serum albumin was 4.19 +/- 0.39 g/dL; 66.66% of prevalent patients had serum albumin level >4 g/dL. The mean serum calcium was 8.66 +/- 1.4 mg/dL, phosphorus was 6.26 +/- 2.54 mg/dL, and approximately 60% of patients had a serum phosphorus level >5.5 mg/dL. The CaxPi product was higher than 55 in around 40% of the cases, and the parathyroid hormone level was in the range of 150 to 300 pg/mL in around 10% of prevalent patients. The mean hemoglobin was 9.23 +/- 7.18 g/dL in prevalent cases; around 70% of cases had a hemoglobin level <11 g/dL. Iron deficiency was prevalent as 18% of patients, with serum ferritin <200 ng/L, and 34% had total serum test <20%. Seventy percent of the patients were hepatitis C virus positive and 4% were hepatitis B surface antigen positive, and all were negative for the human immunodeficiency virus serological test. Dialysis water was monitored regularly for chemical and bacterial contamination as recommended by the American Association for Medical Instrumentation, but an endotoxin assay is currently not included in the monitoring checklist. The annual mortality rate was 8% in 2007. The current audit revealed a reasonable quality of care for HD patients in the fields of vascular access care, dialysis adequacy, and nutrition areas. It also reveals the need for improving anemia management and control of hyperphosphatemia with dietary counseling and more frequent dialysis. To fully meet the guideline targets, each patient should be treated in an individualized way with more counseling, nutritional education, and individualized dialysis prescription. Besides, the unit needs to adopt primary and secondary intervention strategies to prevent and promptly correct any deviation from the desired targets.

PMID: 19758297 [PubMed - as supplied by publisher]

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Impact of American Society of Clinical Oncology/College of American Pathologists guideline recommendations on HER2 interpretation in breast cancer.

Hum Pathol. 2009 Sep 15;

Authors: Shah SS, Ketterling RP, Goetz MP, Ingle JN, Reynolds CA, Perez EA, Chen B

Accurate assessment of human epidermal growth factor receptor 2 is critical for the management of patients with breast cancer. We set out to study the impact of the 2007 American Society of Clinical Oncology/College of American Pathologists guidelines on the interpretation of human epidermal growth factor receptor 2 IHC results and its correlation with fluorescence in situ hybridization results. Invasive breast carcinomas with IHC HercepTest 3+ were retrieved from the archive of Mayo Clinic Rochester. The human epidermal growth factor receptor 2 slides were rereviewed, and results were recorded as percentage of invasive tumor cells with 3+, 2+, 1+, and 0 staining intensity. Human epidermal growth factor receptor 2 gene amplification by fluorescence in situ hybridization was performed on all tumors with 3+ staining in 70% or less of tumor cells. Of the 141 cases studied, 12 cases showed intense membrane staining in 11% to 30% of the invasive tumor cells and would have been scored as 2+ according to the new American Society of Clinical Oncology/College of American Pathologists guidelines. Of these 12 cases, 6 were positive for human epidermal growth factor receptor 2 gene amplification by fluorescence in situ hybridization (ratio >2.2), 4 cases were negative (HER2/CEP17 ratio of < 1.8), and 2 cases were equivocal (ratio of 1.8-2.2). One human epidermal growth factor receptor 2-positive case showed dramatic intratumoral heterogeneity with high-level amplification (ratio of 12.2) in the IHC 3+ area and no amplification (ratio of 1.0) in the IHC 1+/2+ areas. The 2007 American Society of Clinical Oncology/College of American Pathologists guidelines down-scored 2.8% of tumors from human epidermal growth factor receptor 2-positive (IHC 3+) to human epidermal growth factor receptor 2-negative (IHC 2+ equivocal and fluorescence in situ hybridization negative) in this study. Clinical studies are needed to determine whether the updated guidelines are better at predicting response to anti-human epidermal growth factor receptor 2 therapy.

PMID: 19762065 [PubMed - as supplied by publisher]

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Are we there yet? The state of the evidence base for guidelines on breaking bad news to cancer patients.

Eur J Cancer. 2009 Sep 15;

Authors: Paul CL, Clinton-McHarg T, Sanson-Fisher RW, Douglas H, Webb G

The way clinicians break bad news to cancer patients has been retrospectively associated with poor psychosocial outcomes for patients. Education and practice in breaking bad news may be ineffective for improving patients' well-being unless it is informed by a sound evidence base. In the health field, research efforts are expected to advance evidence over time to inform evidence-based practice. Key characteristics of an advancing evidence base are a predominance of new data, and rigorous intervention studies which prospectively demonstrate improved outcomes. This review aimed to examine the progress of the evidence base in breaking bad news to cancer patients. Manual and computer-based searches (Medline and PsycINFO) were performed to identify publications on the topic of breaking bad news to cancer patients published between January 1995 and March 2009. Relevant publications were coded in terms of whether they provided new data, examined psychosocial outcomes for patients or tested intervention strategies and whether intervention studies met criteria for design rigour. Of the 245 relevant publications, 55.5% provided new data and 16.7% were intervention studies. Much of the intervention effort was directed towards improving provider skills rather than patient outcomes (9.8% of studies). Less than 2% of publications were rigorous intervention studies which addressed psychosocial outcomes for patients. Rigorous intervention studies which evaluate strategies for improving psychosocial outcomes in relation to breaking bad news to cancer patients are needed. Current practice and training regarding breaking bad news cannot be regarded as evidence-based until further research is completed.

PMID: 19762227 [PubMed - as supplied by publisher]

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Evidence-based guidelines in the evaluation of work disability: an international survey and a comparison of quality of development.

BMC Public Health. 2009;9:349

Authors: de Boer WE, Bruinvels DJ, Rijkenberg AM, Donceel P, Anema JR

BACKGROUND: In social insurance, the evaluation of work disability is becoming stricter as priority is given to the resumption of work, which calls for a guarantee of quality for these evaluations. Evidence-based guidelines have become a major instrument in the quality control of health care, and the quality of these guidelines' development can be assessed using the AGREE instrument. In social insurance medicine, such guidelines are relatively new. We were interested to know what guidelines have been developed to support the medical evaluation of work disability and the quality of these guidelines. METHODS: Five European countries that were reported to use guidelines were approached, using a recent inventory of evaluations of work disability in Europe. We focused on guidelines that are disease-oriented and formally prescribed in social insurance medicine. Using the AGREE instrument, these guidelines were appraised by two researchers. We asked two experts involved in guideline development to indicate if they agreed with our results and to provide explanations for insufficient scores. RESULTS: We found six German and sixteen Dutch sets of disease-oriented guidelines in official use. The AGREE instrument was applicable, requiring minor adaptations. The appraisers reached consensus on all items. Each guideline scored well on 'scope and purpose' and 'clarity and presentation'. The guidelines scored moderately on 'stakeholder involvement' in the Netherlands, but insufficiently in Germany, due mainly to the limited involvement of patients' representatives in this country. All guidelines had low scores on 'rigour of development', which was due partly to a lack of documentation and of existing evidence. 'Editorial independence' and 'applicability' had low scores in both countries as a result of how the production was organised. CONCLUSION: Disease-oriented guidelines in social insurance medicine for the evaluation of work disability are a recent phenomenon, so far restricted to Germany and the Netherlands. The AGREE instrument is suitably applicable to assess the quality of guideline development in social insurance medicine, but some of the scoring rules need to be adapted to the context of social insurance. Existing guidelines do not meet the AGREE criteria to a sufficient level. The way patients' representatives can be involved needs further discussion. The guidelines would profit from more specific recommendations and, for providing evidence, more research is needed on the functional capacity of people with disabilities.

PMID: 19765295 [PubMed - in process]

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Time needed for a regional emergency medical system to implement resuscitation Guidelines 2005-The Netherlands experience.

Resuscitation. 2009 Sep 17;

Authors: Berdowski J, Schmohl A, Tijssen JG, Koster RW

INTRODUCTION: In December 2005, updated resuscitation Guidelines (G) were introduced worldwide and will be revised again in 2010. This study sought to elucidate how long it takes to implement new guidelines. METHODS: This was a prospective observational study. From July 2005 to January 2008, we included all patients with an out-of-hospital cardiac arrest of suspected cardiac cause. We analyzed Emergency Medical System (EMS) Guideline usage via defibrillator recordings of the continuous ECG and impedance signals. We excluded patients with missing or otherwise unusable ECGs. All shocks and CPR cycles were individually classified. The same Guideline needed to be applied for at least 75% of all shocks and CPR cycles. If no shocks had been given, continuous ECGs were classified by its CPR status only. Continuous ECGs were classified as G1992, G2000 or G2005. If at least 75% of the shocks were given according to G2000 and at least 75% of the CPR was according to G2005, the Guideline protocol was classified as intermediate. All analyses that did not fulfil any Guideline criteria were classified as indeterminate. RESULTS: Of 1672 analyzable resuscitations, 31 (2%) used G1992, 826 (49%) G2000, 608 (36%) G2005, and 125 (7%) intermediate Guidelines. The Guideline protocol could not be identified for the remaining 81 (5%) patients. It took 17 months (from publication) until EMS personnel applied GL2005 in over 80% of cases. CONCLUSION: Our experience shows it took one-and-a-half years to effectively implement new resuscitation Guidelines. We believe improvements in implementation can shorten this to six months.

PMID: 19766376 [PubMed - as supplied by publisher]

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Assessment of CPR-D skills of nursing students in two institutions: reality versus recommendations in the guidelines.

Eur J Emerg Med. 2009 Sep 18;

Authors: Mäkinen M, Axelsson A, Castrén M, Nurmi J, Lankinen I, Niemi-Murola L

Significant differences in basic life support skills including cardiopulmonary resuscitation and defibrillation (CPR-D) were detected when nurses working in one Finnish and one Swedish hospital were tested using an Objective Structured Clinical Examination (OSCE). The purpose of this study was to use OSCE test in assessing guideline based CPR-D skills of newly qualified nurses. The CPR-D skills of newly qualified registered nurses studying in Halmstad University (n = 30), Sweden, Helsinki Metropolia University of Applied Sciences (n = 30), and Finland were assessed using an OSCE which was built up with a case of cardiac arrest with ventricular fibrillation as the initial rhythm. The Angoff average, 32.47, was calculated as cutoff point to pass the test. Forty-seven percent of the students in the Swedish group (mean score 32.47/49, range 26-39, SD 3.76) and 13% of the students in the Finnish group (mean score 23.80/49, range 13-35, SD 4.32) passed the OSCE (P<0.0001), the cutoff point being 32.47. Performance grade for the Swedish group was 2.9/5.0 and for the Finnish group 2.1/5.0 (P<0.0001). Good nontechnical skills correlated with high grading of the clinical skills. In conclusion, CPR-D skills of the newly qualified nurses in both the institutes were clearly under par and were not adequate according to the resuscitation guidelines. Current style of teaching is unlikely to result in students being able to perform adequate CPR-D. Standardized testing would help in controlling the quality of learning.

PMID: 19770665 [PubMed - as supplied by publisher]

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Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV.

BMC Pediatr. 2009;9:59

Authors: Horwood C, Vermaak K, Rollins N, Haskins L, Nkosi P, Qazi S

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities. METHODS: Seventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done. RESULTS: Of 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services. CONCLUSION: The HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.

PMID: 19772599 [PubMed - in process]

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Do Standard Risk Assessment Procedures Adequately Account for Cumulative Risks? An Exploration of the Possibilities Using California's Air Toxics Hot Spots Guidelines.

Int J Toxicol. 2009 Sep 22;

Authors: Salmon AG

Existing risk assessment data and procedures can be used to address the estimation of cumulative risk, but there are several uncertainties. These are explored in the context of the State of California's Air Toxic Hot Spots program. Hazard identification for single agents is an established procedure but is much more complex for incompletely characterized or variable mixtures. Hazards from exposure to multiple agents are often only identified by chance. Similar concerns affect dose-response assessment. Although additivity is assumed by default for similar effects at low doses, exceptions are known for specific mixtures and for higher dose rates. Exposure assessment is especially complex for multiple sources, multiple agents from different sources, and target populations or individuals who face cumulative, but not necessarily simultaneous, impacts. With these contributory uncertainties, providing an integrated analysis that can inform risk management and presenting this to a diverse and often already stressed community are challenging.

PMID: 19773591 [PubMed - as supplied by publisher]

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Non-adherence to guidelines: an avoidable cause of failure of empirical antimicrobial therapy in the presence of difficult-to-treat bacteria.

Intensive Care Med. 2009 Sep 24;

Authors: Garcin F, Leone M, Antonini F, Charvet A, Albanèse J, Martin C

PURPOSE: To identify the risk factors of ventilator-associated pneumonia (VAP) due to difficult-to-treat (DTT) bacteria (i.e., Pseudomonas aeruginosa, Acinetobacter baumannii and oxacillin-resistant Staphylococcus aureus), and to assess the rate and the causes of inappropriateness of empirical antimicrobial therapy. METHODS: In an intensive care unit of a university hospital, patients with VAP were empirically treated with antibiotics without activity against DTT bacteria if the patients had no prior hospitalization or prior administration of antibiotics, according to local guidelines. RESULTS: Overall, the empirical antimicrobial therapy was appropriate in 190 (87%) out of 218 patients with VAP. Fifty (23%) patients developed problems due to DTT bacteria. The risk factors for VAP due to DTT bacteria were shock state, prior antimicrobial therapy, prior stay in long-term care facilities and late-onset VAP. Empirical antimicrobial therapy was inappropriate in 20 (40%) patients with VAP due to DTT bacteria and 8 (5%) patients with VAP due to non-DTT (P = 0.001). Guidelines violations (nine patients), bacteria not included in antibiotic spectrum (eight patients) and bacterial resistance (three patients) were the causes of inappropriateness in case of DTT bacteria. CONCLUSION: Despite the abundant information for the treatment of VAP and the establishment of guidelines, too many patients with DTT bacteria received inappropriate antimicrobial therapy. Since 45% of the cases are related to non-adherence to the local protocol, there is room for improvement by implementing educational programs. Also, since DTT bacteria are found in 23% of late-onset VAP, empirical antibiotic treatment should be directed against these pathogens.

PMID: 19777208 [PubMed - as supplied by publisher]

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[Women aged 50-74 years follow-up after cervical cytological Ascus abnormalities in cancer screening: Adherence to the clinical practice guideline in Isere, France; 1991-2000.]

Gynecol Obstet Fertil. 2009 Sep 24;

Authors: Billette-de-Villemeur A, Poncet F, Garnier A, Marron J, Le Marc’hadour F, Morens A, Rouault-Plantaz V, Ney M, Exbrayat C

OBJECTIVES: The aim of this study is to compare to the guideline (1998 and 2001) the follow-up of Ascus cytological abnormalities among women aged 50-74 years who have participated at the combined breast, cervical and colorectal cancer screening programme from 1991 to 2000 in Isère, France. PATIENTS AND METHODS: The follow-up of 1154 women with Ascus smear was analysed. A woman was defined according follow-up if she have made a colposcopy or biopsy less than four months after one positive smear or if she has repeated three smears: 3-7 months and 10-14 months after the positive smear and 1 year after the last negative smear. RESULTS: The follow-up was according to guidelines for 28,4% of the 1154 women (150 women are unknowns), 58,6% had a follow-up with too long delay and 17,2% had an uncompleted follow-up. The follow-up did not differ before 1998. It did not differ from women age. Women who were treated by gynaecologist (548) had a better follow-up (according: 35,4%) than the women who were treated by a general practitioner (595). DISCUSSION AND CONCLUSION: The follow-up of Ascus cytological abnormalities is not according to guideline. The follow-up in the screening program will be intensified.

PMID: 19782628 [PubMed - as supplied by publisher]

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