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Implementation of guidelines on oxytocin use at caesarean section: A survey of practice in Great Britain and Ireland.

Eur J Obstet Gynecol Reprod Biol. 2009 Nov 5;

Authors: Sheehan SR, Wedisinghe L, Macleod M, Murphy DJ

OBJECTIVE: Caesarean section is one of the most commonly performed major operations on women worldwide. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. Various clinical guidelines address oxytocin use at the time of caesarean section. We previously reported wide variation in practice amongst clinicians in the United Kingdom in the use of oxytocin at caesarean section. The aim of this current study was to determine whether the variation in approach is universal across the individual countries of Great Britain and Ireland and whether this reflects differences in interpretation and implementation of clinical practice guidelines. STUDY DESIGN: We conducted a survey of practice in the five individual countries of Great Britain and Ireland. A postal questionnaire was sent to all lead consultant obstetricians and anaesthetists with responsibility for the labour ward. We explored the use of oxytocin bolus and infusion, the measurement of blood loss at caesarean section and the rates of major haemorrhage. Existing clinical guidelines from the National Institute for Clinical Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and ALSO (Advanced Life Support in Obstetrics) were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section. RESULTS: The response rate was 82% (391 respondents). Use of a 5IU oxytocin bolus was reported by 346 respondents (85-95% for individual countries). In some countries, up to 14% used a 10IU oxytocin bolus despite recommendations against this. Routine use of an oxytocin infusion varied greatly between countries (11% lowest-55% highest). Marked variations in choice of oxytocin regimens were noted with inconsistencies in the country-specific recommendations, e.g. NICE (which covers England and Wales) recommends a 30IU oxytocin infusion over 4h, but only 122 clinicians (40%) used this. CONCLUSIONS: Clinicians' approach to the use of oxytocin at the time of caesarean delivery varies between countries. Even in countries with on-site visits to ensure guideline implementation (e.g. Clinical Negligence Scheme for Trusts in England), deviations from guideline recommendations exist. These variations may reflect a lack of robust evidence and the need for future research in this area.

PMID: 19896761 [PubMed - as supplied by publisher]

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[Guideline for radioimmunotherapy of CD20+ follicular B-cell non-Hodgkin s lymphoma.]

Nuklearmedizin. 2009 Nov 9;48(6)

Authors: Fischer M, Grünwald F, Knapp WH, Trümper L, von Schilling C, Dreyling M

This guideline is a prerequisite for the quality management in the treatment of non-Hodgkon- lymphomas in patients with relapsed or refractory follicular lymphoma after rituximab therapy and as consolidation therapy after first remission following CHOP like treatment using radioimmunotherapy. It is based on an interdisciplinary consensus and contains background information and definitions as well as specified indications and detailed contraindications of treatment. Essential topics are the requirements for institutions performing the therapy. For instance, presence of an expert for medical physics, intense cooperation with all colleagues committed to treatment of lymphomas, and a certificate of instruction in radiochemical labelling and quality control are required. Furthermore, it is specified which patient data have to be available prior to perform- Correspondence to: Prof. Dr. Manfred Fischer Im Bodden 60, 34125 Kassel, Germany ance of therapy and how treatment has to be carried out technically. Here, quality control and documentation of labelling are of great importance. After treatment, clinical quality control is mandatory (work-up of therapy data and followup of patients). Essential elements of follow-up are specified in detail. The complete treatment inclusive after-care has to be realised in close cooperation with those colleagues (hemato-oncologists) who propose, in general, radioimmunotherapy under consideration of the development of the disease.

PMID: 19902120 [PubMed - as supplied by publisher]

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Comparative trends in guidelines adherence among patients with non-ST-segment elevation acute coronary syndromes treated with invasive versus conservative management strategies: Results from the CRUSADE quality improvement initiative.

Am Heart J. 2009 Nov;158(5):748-754.e1

Authors: Amsterdam EA, Peterson ED, Ou FS, Newby LK, Pollack CV, Gibler WB, Ohman EM, Roe MT

BACKGROUND: Prior studies have demonstrated differences in adherence to non-ST-segment elevation acute coronary syndromes (NSTE ACS) guidelines-recommended therapies among patients managed conservatively without cardiac catheterization compared with those managed invasively. We evaluated the degree of yearly change in use of guidelines-recommended therapies for patients with NSTE ACS in CRUSADE stratified by use of cardiac catheterization and revascularization procedures. METHODS: We analyzed data from 138,714 high-risk patients with NSTE ACS treated at 547 hospitals during the first 4 years of the CRUSADE initiative. Patients were categorized as no cardiac catheterization (29% of the total population), cardiac catheterization without revascularization (21%), percutaneous coronary intervention (40%), and coronary artery bypass graft surgery (11%). Composite guidelines adherence scores were used to compare yearly changes in use of guidelines-recommended therapies among the groups. RESULTS: Although guidelines adherence improved in all 4 groups each year and was consistently highest in the percutaneous coronary intervention group, the adjusted yearly increase in the use of acute guidelines-recommended medications was highest in the no cardiac catheterization group, and the adjusted yearly increase in the use of discharge medications was highest in the coronary artery bypass graft surgery group. CONCLUSIONS: Improvements in the use of guidelines-recommended therapies were seen among all patients with NSTE ACS in CRUSADE over a 4-year period regardless of management strategy, and the trajectory of improvement in acute care was greatest in patients managed conservatively.

PMID: 19853692 [PubMed - in process]

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Are current guidelines for categorization of visual impairment in India appropriate?

Indian J Ophthalmol. 2009 Nov-Dec;57(6):423-6

Authors: Monga PK, Parwal BP, Rohatgi J, Dhaliwal U

CONTEXT : Visual disability in India is categorized based on severity. Sometimes the disabled person does not fit unambiguously into any of the categories. AIMS : To identify and quantify disability that does not fit in the current classification, and propose a new classification that includes all levels of vision. SETTINGS AND DESIGN : Retrospective chart review of visual disability awarded in a teaching hospital. MATERIALS AND METHODS : The last hundred records of patients who had been classified as visually disabled were screened for vision in both eyes and percentage disability awarded. Data were handled in accordance with the Helsinki Declaration. RESULTS : Twenty-one patients had been classified as having 30% disability, seven each had 40% and 75%, and 65 had 100% disability. Eleven of them did not fall into any of the current categories, forcing the disability board to use its own judgment. There was a tendency to over-grade the disability (seven of 11; 63.6%). The classification proposed by us is based on the national program for control of blindness’ definition of normal vision (20/20 to 20/60), low vision ( < 20/60 to 20/200), economic blindness ( < 20/200 to 20/400) and social blindness ( < 20/400). It ranges from the mildest disability (normal vision in one eye, low vision in the other) up to the most severe grade (social blindness in both eyes). CONCLUSIONS : The current classification of visual disabilities does not include all combinations of vision; some disabled patients cannot be categorized. The classification proposed by us is comprehensive, progresses logically, and follows the definitions of the national program.

PMID: 19861742 [PubMed - in process]

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Evaluation of anti-wrinkle effects of a novel cosmetic containing retinol using the guideline of the Japan Cosmetic Industry Association.

J Dermatol. 2009 Nov;36(11):583-6

Authors: Kawada A, Konishi N, Momma T, Oiso N, Kawara S

Retinol is known to be effective in the treatment of sallowness, wrinkling, red blotchiness and hyperpigmented spots in aging skin. In this study, we have evaluated the anti-wrinkle effects of a new cosmetic containing retinol. An open study was performed in 30 healthy Japanese women who had wrinkles at the corners of the eyes. The tested lotion, Retin-OX+ (RoC SA, Colombes, France), was applied on wrinkles of one side of the face for 8 weeks, and not on the other site as a control. Anti-wrinkle effects were evaluated by two methods: (i) doctors’ observation and photos based on the guideline of the Japan Cosmetic Industry Association; and (ii) the Robo Skin Analyzer. This lotion showed marked and moderate improvement in 34% of the subjects with a significant difference as compared with the control sites (P < 0.05). Moreover, the length and area decreased in the applied site more than the control site with a significant difference (P < 0.01). All the patients completed the study without significant adverse reactions. The tested lotion was well tolerated and may be an optional preparation for the treatment of wrinkles at the corner of the eyes.

PMID: 19878390 [PubMed - in process]

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2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

Circulation. 2009 Nov 2;

Authors: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF

PMID: 19884473 [PubMed - as supplied by publisher]

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The 2009 American Thyroid Association Guidelines for management of thyroid nodules and differentiated thyroid cancer: progress on the road from consensus- to evidence-based practice.

Thyroid. 2009 Nov;19(11):1145-7

Authors: Puxeddu E, Filetti S

PMID: 19888856 [PubMed - in process]

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Despite evidence-based guidelines, systolic blood pressure remains inadequately controlled in older hypertensive adults.

J Hum Hypertens. 2009 Nov 5;

Authors: Antikainen RL, Kastarinen MJ, Jousilahti P, Peltonen M, Laatikainen T, Beckett N, Peters R, Jokelainen J, Barengo NC, Tuomilehto JO

We aimed to assess the trends in the prevalence, awareness, treatment and control of hypertension in Finnish men and women aged 60-74 years. Three independent cross-sectional population surveys were conducted in 1997, 2002 and 2007 in the province of North Karelia and the region of Helsinki-Vantaa. Random samples were selected from the national population register. The total number of participants was 3282. In 2007, the prevalence of hypertension was 79% in men and 78% in women. The mean systolic blood pressure (SBP) (in men, 151 mm Hg in 1997, 148 mm Hg in 2002 and 149 mm Hg in 2007; in women 150, 149 and 149 mm Hg, respectively) and prevalence of hypertension (77% in 1997, 74% in 2002 and 79% in 2007 in men; 75, 75 and 78% in women, respectively) remained stable. The mean diastolic blood pressure (BP) decreased in both genders. Awareness of hypertension increased from 60 to 71% in men (P<0.001 for trend) and from 66 to 76% (P=0.012) in women. The prevalence of antihypertensive drug treatment among hypertensive people increased from 35 to 56% in both genders (P<0.001). The proportion of treated hypertensive patients with adequately controlled BP increased from 16 to 32% in men (P<0.001) and from 16 to 30% in women (P=0.003). Hypertension care in older adults has improved in Finland during 1997 to 2007. The situation is not optimal: the main problem in this age group is high SBP.Journal of Human Hypertension advance online publication, 5 November 2009; doi:10.1038/jhh.2009.85.

PMID: 19890369 [PubMed - as supplied by publisher]

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[Therapy with blood components and plasma derivatives : The current cross-sectional guidelines.]

Anaesthesist. 2009 Nov 6;

Authors: Biscoping J

PMID: 19890616 [PubMed - as supplied by publisher]

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[Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists.]

J Gynecol Obstet Biol Reprod (Paris). 2009 Nov 3;

Authors: Eckman A, Ramanah R, Gannard E, Clement MC, Collet G, Courtois L, Martin A, Cossa S, Maillet R, Riethmuller D

AIM: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS: : In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001). CONCLUSION: An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.

PMID: 19892475 [PubMed - as supplied by publisher]

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