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[Application of HIV drug resistance testing according to guidelines]

Dtsch Med Wochenschr. 2009 Nov;134(46):2342-5

Authors: Oette M, Göbels K, Reuter S, Koch S, Kaiser R, Häussinger D

Guidelines for application of HIV drug resistance testing have recently been develeped in Europe and the USA. This article discusses these recommendations. Since the widespread use of highly active antiretroviral therapy (HAART), quality of life has been improved for the majority of HIV-infected patients and the mortality rate has declined significantly. However, an incomplete suppression of viral replication results in selection of resistant viral strains resulting in a loss of HAART efficacy and worsening in the quality of life. Resistance testing is likely to improve virological monitoring of untreated but especially in pre-treated patients. Genotypical and phenotypical assays present similar results, but genotypical testing is the method of choice initially. Translation of resistance testing into clinical decisions-making requires consideration of a patient’s history, interpretation of results by a validated algorithm, and expert advice. Problems of adherence should be avoided by counselling and therapeutic drug monitoring. Resistance testing or storage of a patient’s plasma sample should be undertaken as early as possible in the disease history. If this is not possible, treatment with HAART, including a boosted protease inhibitor, is warranted. European and USA guidelines present similar recommendations. HIV drug resistance is preventable by rational choice of drug combinations in HAART. After development of resistance-associated mutations, drug resistance testing can preserve future treatment options and preventing further clinical deterioration. The method has been incorporated into national and international guidelines on the basis of good scientific evidence.

PMID: 19894202 [PubMed - in process]

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[Influence of acute stroke care organization on the implementation of clinical practice guidelines.]

Rev Neurol (Paris). 2009 Nov;165(11):949-56

Authors: Bodiguel E, Thiery R, Lairy G, Woimant F

INTRODUCTION: Patients who receive care in a dedicated stroke unit are more likely to survive and become independent. Specific guidelines describe evidence-based care practices. We examined the results of a French audit validation campaign to determine whether the presence of a stroke unit had an influence on the implementation of these recommendations. METHODS: Eleven hospital centers volunteered for self-evaluation. Care delivered to patients in the emergency room and in the hospital unit (dedicated stroke unit or not) was assessed with the clinical audit method. RESULTS: Compared with non-dedicated units, care delivered in stroke units was significantly more compliant with published recommendations. All aspects of acute stroke care were concerned: initial evaluation, acute phase treatment, screening for complications and their treatment, multidisciplinary team coordination, discharge preparation. Care delivered in dedicated stroke units was more reproducible, protocols were more widely used, acute phase risks were better prevented, and acute and postacute care was better coordinated between professionals. A second audit one year later showed increased quality of care in both dedicated and non-dedicated units, with more items improved in the latter. CONCLUSION: Although statistical bias cannot be excluded, this study suggests that recommendations are applied better in dedicated stroke units. A second audit showed better compliance with recommendations, especially in non-dedicated units.

PMID: 19356779 [PubMed - in process]

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Survival rates of extremely preterm infants (gestational age <26 weeks) in Switzerland: impact of the Swiss guidelines for the care of infants born at the limit of viability.

Arch Dis Child Fetal Neonatal Ed. 2009 Nov;94(6):F407-13

Authors: Fischer N, Steurer MA, Adams M, Berger TM,

BACKGROUND: Because ethical decision making in the care of extremely preterm infants varies widely across Europe, the Swiss Society of Neonatology decided to publish its own guidelines on the care of infants born at the limit of viability in 2002. OBJECTIVE: To examine the potential impact of the guidelines on survival rates, short-term complication rates and centre-to-centre outcome differences of extremely preterm infants (22-25 completed weeks). DESIGN: Population-based, retrospective cohort study. SETTING: All nine level III neonatal intensive care units (NICU) and affiliated paediatric hospitals in Switzerland. PATIENTS: 516 extremely preterm infants born alive between 1 January 2000 and 31 December 2004. MAIN OUTCOME MEASURES: Delivery room and NICU mortality rates, survival to hospital discharge and incidence of short-term complications in survivors were assessed. To study the impact of the guidelines, two cohorts from two different time periods were compared (years 2000/2001, n = 220; years 2003/2004, n = 204) whereas patients born in the year of the publication (2002, n = 92) were excluded. For centre-to-centre comparisons, the entire population (n = 516) was analysed. RESULTS: There was a significant increase in survival rates of extremely preterm infants from 31% to 40% (RR 1.24, 95% CI 1.02, 1.50) after the publication of the Swiss guidelines. This improvement was largely explained by significantly improved survival from 42% to 60% (p = 0.01) among infants born at 25 completed weeks because of decreased NICU mortality. Improved survival was not associated with statistically significant changes in the incidence of short-term complications. Despite national guidelines, considerable centre-to-centre outcome differences have persisted. CONCLUSIONS: The publication of the Swiss guidelines was followed by significantly improved survival of extremely preterm infants but had no impact on centre-to-centre differences.

PMID: 19357122 [PubMed - in process]

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Management guidelines for the use of alemtuzumab in chronic lymphocytic leukemia.

Leukemia. 2009 Nov;23(11):1980-8

Authors: Osterborg A, Foà R, Bezares RF, Dearden C, Dyer MJ, Geisler C, Lin TS, Montillo M, van Oers MH, Wendtner CM, Rai KR

The consensus views of an expert roundtable meeting are presented as updated management guidelines for using alemtuzumab in chronic lymphocytic leukemia. Since the publication of previous management guidelines in 2004, clinical experience with alemtuzumab has grown significantly, especially regarding its efficacy and safety, management of cytomegalovirus (CMV) reactivation, identification of patient subgroups likely to benefit from alemtuzumab therapy and subcutaneous administration of alemtuzumab. The updated recommendations include (1) alemtuzumab monotherapy can be safely used as first-line therapy; (2) suitable patient subgroups for alemtuzumab therapy include elderly patients, patients with 17p deletion, patients with refractory autoimmune cytopenias and patients with profound pancytopenia at baseline due to heavily infiltrated bone marrow; (3) alemtuzumab treatment should be continued for 12 weeks (36 doses) whenever possible, and bone marrow examination may be considered at week 12 to evaluate response; (4) monitoring CMV reactivation by weekly PCR is mandated during therapy; when CMV reactivation becomes symptomatic or viremia increases, alemtuzumab therapy should be interrupted and anti-CMV therapy started; (5) subcutaneous administration is safe, easy to perform and appears equally effective compared with intravenous infusion and (6) our strong recommendation is that alemtuzumab combination therapy and consolidation therapy shall not be used outside carefully controlled clinical studies.

PMID: 19626051 [PubMed - in process]

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Adherence to food-based dietary guidelines and evaluation of nutrient intake in 7-year-old children.

Public Health Nutr. 2009 Nov;12(11):1999-2008

Authors: Kristjansdottir AG, Thorsdottir I

OBJECTIVE: To evaluate the diet of 7-year-old children by comparison with food-based dietary guidelines (FBDG) and reference values for nutrient intake. DESIGN: Food and nutrient intake was assessed by 3 d weighed dietary records of 7-year-olds in six randomly chosen schools in Reykjavik, Iceland. Height and weight were measured. The diet of 165 children (62 % of sample) was evaluated by the Icelandic FBDG and the Nordic reference values (NRV) for nutrient intake. SETTING: Six randomly chosen schools in Reykjavik, Iceland. RESULTS: The FBDG on fruits and vegetables was reached by less than 20 % of the children. A total of 52 % reached the FBDG to eat fish twice a week and 41 % to use vitamin D supplement. The FBDG on dairy was reached by 66 % of the children. Mean intake of SFA gave 13.9 % of the total energy intake (E%), which is higher than the NRV, 9.3E% of MUFA and 3.8E% of PUFA, both lower than the NRV (for all differences P < 0.001). Added sugar gave 12.1E%, which exceeds the upper level (P < 0.001). Fibre intake was 2.1 g/MJ and lower than the NRV (P < 0.001). Mean intake of micronutrients was above the recommended intake (RI), except for iodine, 109.0 microg/d, and vitamin D, 6.1 microg/d, which was lower than the RI (P = 0.006 and P < 0.001, respectively). CONCLUSIONS: Fruit, vegetable, fish and dairy, as well as vitamin D supplement, need to be increased in the diet of 7-year-old children to reach the FBDG and the reference values for nutrient intake. Dietary changes to increase the quality of fat and carbohydrate are needed as well.

PMID: 19656438 [PubMed - in process]

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Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).

Eur Heart J. 2009 Nov;30(22):2769-812

Authors: Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe G, Vermassen F, Hoeks SE, Vanhorebeek I, ,

PMID: 19713421 [PubMed - in process]

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Adult community-acquired bacterial meningitis requiring ICU admission: epidemiological data, prognosis factors and adherence to IDSA guidelines.

Eur J Clin Microbiol Infect Dis. 2009 Nov;28(11):1317-25

Authors: Georges H, Chiche A, Alfandari S, Devos P, Boussekey N, Leroy O

Numerous guidelines are available to guide empirical antimicrobial therapy (EAT) in acute bacterial meningitis (ABM) patients. We analysed prognosis factors and compliance to the Infectious Diseases Society of America (IDSA) guidelines in ABM patients requiring stay in an intensive care unit (ICU). A 10-year retrospective study, using prospectively collected data, in 82 ABM patients admitted to a 16-bed university-affiliated French ICU was undertaken. Seventeen patients (20.7%) died during ICU stay. Multivariate analysis isolated four factors associated with in-ICU death: alcoholism (P = 0.007), acute kidney injury (P = 0.006), age >60 years (P = 0.006) and ICU admission for neurological failure (P = 0.01). Causative pathogens were isolated for 62 (75.6%) patients, including 29 pneumococci, 14/28 of which were non-susceptible to penicillin. No characteristics, particularly recent hospitalisation and/or antibiotic delivery, was associated with penicillin susceptibility. Compliance to IDSA guidelines was 65%. Non-compliance concerned to be essentially the non-delivery or low dosage of vancomycin. Treatment compatible with IDSA guidelines was associated with a decreased ICU mortality in univariate (61.5% survival vs. 35.3%, P = 0.05) but not in multivariate analysis. In-ICU mortality associated with ABM remains high. Prognosis factors are related to the severity of disease or underlying conditions. Penicillin non-susceptible Streptococcus pneumoniae can occur without any of the usual predisposing factors.

PMID: 19727871 [PubMed - in process]

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Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET).

Thromb Res. 2009 Nov;124(5):e6-e12

Authors: Cosmi B, Alatri A, Cattaneo M, Gresele P, Marietta M, Rodeghiero F, Tripodi A, Ansaloni L, Fusari M, Taddei S

SYNOPSIS OF RECOMMENDATIONS: The Italian Society for Thrombosis and Haemostasis (SISET: Società Italiana per lo Studio dell' Emostasi e della Trombosi) promoted the development of a series of guidelines which would adopt evidence-based medicine methodology on clinically relevant problems in the field of haemostasis and thrombosis. The objective of the present guidelines is to provide recommendations for the pre-operative and pre-procedural assessment of the bleeding risk with the aim of reducing the incidence of preventable bleeding complications and limiting laboratory tests to the those necessary. The predictive value of haemostatic tests for bleeding complications after surgery or invasive procedures has been evaluated in prospective or retrospective cohort studies only. All retrieved studies were of low methodological quality with a high potential for bias because none conducted a blinded outcome assessment. In addition, different criteria for the severity of bleeding events and different reference values of the laboratory tests were adopted. The low methodological quality limits the validity of the results of these studies. Some of the clinical queries proposed by the working group were not addressed by the studies available in the literature. The areas with evidence, although of low quality, are the following: general surgery in adults (for history, PT, APTT, platelet count and bleeding time), neurosurgery in adults (for history, PT, APTT, platelet count), adenotonsillectomy in children (for history, PT, APTT, platelet count and bleeding time), invasive procedures in adults (for PT, APTT, platelet count), dental extractions (for the bleeding time only), cataract extraction (for platelet count). No studies are available in children for major surgery other than adenotonsillectomy, neurosurgery and invasive procedures.

PMID: 19740528 [PubMed - in process]

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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 Nov;45(17):2960-6

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 - in process]

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Evidence-based guidelines for cardiovascular risk reduction: the safety and efficacy of high-dose statin therapy.

J Cardiovasc Nurs. 2009 Nov-Dec;24(6):429-38

Authors: Ashen MD, Foody JM

Current clinical guidelines for management of low-density lipoprotein cholesterol (LDL-C) have evolved to reflect the findings of numerous randomized clinical trials and represent an important opportunity to effectively improve the cardiovascular (CV) risk profile of a wide range of patients. Implementation of guideline-recommended LDL-C management strategies facilitates the appropriate use of all available treatments, including lifestyle and dietary changes and pharmacotherapy. Where intensive lowering of LDL-C is required, suboptimal use of statins is a major contributor to the significant number of patients who remain at an unnecessarily increased risk of CV disease as a consequence of failing to reach their guideline-recommended LDL-C goals. This underuse may be explained by concerns over the safety and efficacy of high-dose statin regimens in certain populations. These issues are explored in the context of current, evidence-based clinical guidelines for LDL-C management and, through 3 hypothetical case studies, selection of appropriate starting doses of statins, and titration to a higher dose or switching to a more potent statin, to ensure that patients reach their individual LDL-C goals and reduce their overall CV risk, is also examined.

PMID: 19786883 [PubMed - in process]

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