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Adherence to guideline-recommended adjunctive heart failure therapies among outpatient cardiology practices (findings from IMPROVE HF).

Am J Cardiol. 2010 Jan 15;105(2):255-60

Authors: Yancy CW, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN

Although previous studies have documented adherence with certain established heart failure (HF) quality metrics in outpatient cardiology practices, the extent to which there is conformity with other evidence-based, guideline-driven quality metrics in outpatients with HF is unknown. IMPROVE HF is a prospective cohort study designed to characterize the current management of patients with chronic HF and left ventricular ejection fraction

PMID: 20102928 [PubMed - in process]

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Ergonomic Evaluation and Guidelines for Use of the daVinci Robot System.

J Endourol. 2010 Jan 14;

Authors: Lux MM, Marshall M, Erturk E, Joseph JV

Abstract Introduction: The daVinci Robot system has been widely lauded for its improved ergonomic characteristics when compared with the pure laparoscopic technique. Our goal in this study was to assess for the existence of guidelines to maximize the ergonomic benefits of the daVinci system. We also compared the surgeon's console with the recommendations of similar workstations. Methods: A literature review of seated ergonomics was performed to identify recommendations for work areas similar to the robotic system, where prolong seating is necessary. An upper body biomechanics and ergonomic expert was consulted to evaluate the daVinci system and aid in the formation of ergonomic positioning guidelines. Link-length proportions were used to evaluate size constraints of potential robot operators. Results: No published guidelines exist for proper positioning using the daVinci surgeon console. There are, however, several Occupational Safety and Health Administration workstation guidelines as well as microscope ergonomic guidelines. The use of link-length proportions showed that the surgeon console allows a comfortable posture for individuals with height between 64 and 73 inches. Review of the microscope ergonomics literature indicates that a neutral vertical seating position has been associated with decreased strain and musculoskeletal disorders. Conclusions: The body mechanics of the daVinci robot system best mimics that of microscopy. Future surgeon console modifications could emulate those reported in the microscope ergonomic literature, where a neutral vertical position has been recommended. This may help avoid potential musculoskeletal disorders similar to those previously seen with microscopy usage. Guidelines are suggested to optimize the surgeon's console position.

PMID: 20073561 [PubMed - as supplied by publisher]

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Evidence-based Guidelines for Perioperative Management of Diabetes in Cardiac and Vascular Surgery.

World J Surg. 2010 Jan 14;

Authors: Wong J, Zoungas S, Wright C, Teede H

BACKGROUND: Management of patients with hyperglycaemia undergoing vascular and cardiac surgery is important, with mounting evidence that hyperglycaemia in this setting is associated with worse outcomes. Evidence-based guidelines for the management of these patients have been limited. METHODS/RESULTS: Our institution was aware of the lack of standardization of care in this growing population group and formed a multidisciplinary guideline development group to develop evidence-based guidelines to standardize the perioperative management of hyperglycaemia. CONCLUSION: This series of articles outlines the process of developing evidence-based guidelines and the recommendations for perioperative management of patients with hyperglycaemia and diabetes undergoing cardiac and vascular surgery at our institution.

PMID: 20076958 [PubMed - as supplied by publisher]

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Small renal masses: current concepts regarding the natural history and reflections on the American Urological Association guidelines.

Curr Opin Urol. 2010 Jan 13;

Authors: Mues AC, Landman J

PURPOSE OF REVIEW: Although surgical resection is the current standard for treatment of small (<4 cm) renal cortical neoplasms, active surveillance remains an option in selected patients depending on tumor characteristics and surgical risk. We review the natural history of small renal masses according to the current literature, and highlight issues regarding the recent guidelines for the management of T1 renal masses put forth by the American Urological Association. RECENT FINDINGS: The natural history of small renal masses is still largely unknown; however, initial size or volume of the mass seems to predict the risk of malignancy in retrospective studies. A new study found that growth rate is inversely related to initial tumor volume, with smaller masses growing faster in the beginning and decreasing in rate of growth as they enlarge. Biomarkers such as carbonic anhydrase IX, vascular endothelial growth factor, and CD147 have demonstrated some value in predicting tumor characteristics and prognosis in renal cell carcinoma. Finally, we suggest modifications to the new American Urological Association guidelines based on the authors' experience in order to optimize the management of renal cortical neoplasms. SUMMARY: The natural history of small renal masses is not completely understood. Growth rate and tumor size are factors shown to be predictive of tumor biology. Currently, there are no specific tumor markers to determine initial risk or progression to metastatic disease; however, investigation into new molecules is being undertaken. The guidelines presented by the American Urological Association give a formal framework for the management of T1 renal cortical neoplasms; however, we site specific modifications and recommend that they be considered when evaluating patients for treatment.

PMID: 20075734 [PubMed - as supplied by publisher]

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The REFLECT Statement: Reporting Guidelines for Randomized Controlled Trials in Livestock and Food Safety: Explanation and Elaboration.

Zoonoses Public Health. 2010 Jan 12;

Authors: Sargeant JM, O'connor AM, Gardner IA, Dickson JS, Torrence ME, , Dohoo IR, Lefebvre SL, Morley PS, Ramirez A, Snedeker K

Abstract Concerns about the completeness and accuracy of reporting of randomized clinical trials (RCTs) and the impact of poor reporting on decision making have been documented in the medical field over the past several decades. Experience from RCTs in human medicine would suggest that failure to report critical trial features can be associated with biased estimated effect measures, and there is evidence to suggest that similar biases occur in RCTs conducted in livestock populations. In response to these concerns, standardized guidelines for reporting RCTs were developed and implemented in human medicine. The Consolidated Standards of Reporting Trials (CONSORT) statement was first published in 1996, with a revised edition published in 2001. The CONSORT statement consists of a 22-item checklist for reporting a RCT and a flow diagram to follow the number of participants at each stage of a trial. An explanation and elaboration document not only defines and discusses the importance of each of the items, but also provides examples of how this information could be supplied in a publication. Differences between human and livestock populations necessitate modifications to the CONSORT statement to maximize its usefulness for RCTs involving livestock. These have been addressed in an extension of the CONSORT statement titled the REFLECT statement: Methods and processes of creating reporting guidelines for randomized control trials for livestock and food safety. The modifications made for livestock trials specifically addressed the common use of group housing and group allocation to intervention in livestock studies; the use of deliberate challenge models in some trials and the common use of non-clinical outcomes, such as contamination with a foodborne pathogen. In addition, the REFLECT statement for RCTs in livestock populations proposed specific terms or further clarified terms as they pertained to livestock studies.

PMID: 20070652 [PubMed - as supplied by publisher]

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Systematic review of guidelines on cardiovascular risk assessment: Which recommendations should clinicians follow for a cardiovascular health check?

Arch Intern Med. 2010 Jan 11;170(1):27-40

Authors: Ferket BS, Colkesen EB, Visser JJ, Spronk S, Kraaijenhagen RA, Steyerberg EW, Hunink MG

OBJECTIVE: To appraise guidelines on cardiovascular risk assessment to guide selection of screening interventions for a health check. DATA SOURCES: Guidelines in the English language published between January 1, 2003, and May 2, 2009, were retrieved using MEDLINE and CINAHL. This was supplemented by searching the National Guideline Clearinghouse, National Library for Health, Canadian Medical Association Infobase, and G-I-N International Guideline Library. STUDY SELECTION: We included guidelines developed on behalf of professional organizations from Western countries, containing recommendations on cardiovascular risk assessment for the apparently healthy population. Titles and abstracts were assessed by 2 independent reviewers. Of 1984 titles identified, 27 guidelines met our criteria. DATA EXTRACTION: Rigor of guideline development was assessed by 2 independent reviewers. One reviewer extracted information on conflicts of interest and recommendations. RESULTS: Sixteen of 27 guidelines reported conflicts of interest and 17 showed considerable rigor. These included recommendations on assessment of total cardiovascular risk (7 guidelines), dyslipidemia (2), hypertension (2), and dysglycemia (7). Recommendations on total cardiovascular risk and dyslipidemia included prediction models integrating multiple risk factors, whereas remaining recommendations were focused on single risk factors. No consensus was found on recommended target populations, treatment thresholds, and screening tests. CONCLUSIONS: Differences among the guidelines imply important variation in allocation of preventive interventions. To make informed decisions, physicians should use only the recommendations from rigorously developed guidelines.

PMID: 20065196 [PubMed - in process]

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Screening for high-risk cardiovascular disease: a challenge for the guidelines: comment on "systematic review of guidelines on cardiovascular risk assessment: which recommendations should clinicians follow for a cardiovascular health check?".

Arch Intern Med. 2010 Jan 11;170(1):40-2

Authors: Smith SC

PMID: 20065197 [PubMed - in process]

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Experiences of the implementation of clinical practice guidelines - interviews with nurse managers and nurses in hospital care.

Scand J Caring Sci. 2010 Jan 11;

Authors: Bahtsevani C, Willman A, Stoltz P, Ostman M

Scand J Caring Sci; 2010 Experiences of the implementation of clinical practice guidelines - interviews with nurse managers and nurses in hospital care The implementation of clinical practice guidelines (CPGs) has become an increasingly common element of clinical care, but little qualitative research has been conducted in real-life clinical settings. The aim was to elucidate experiences and factors of importance for the implementation of CPGs in hospital care. Twenty interviews were conducted, audio-taped and transcribed verbatim. A manifest and latent content analysis was performed to interpret the text. A system of subcategories related to five categories and one overall theme were developed. The data reveal that the implementation of CPGs is continuous processes of creating reliable and tenable routines that involve all staff members and expect to lead to better and safer patient care as well as to increased knowledge and confidence among staff. The process is initiated by internal or external demands and represents a way to keep abreast of knowledge development. Several factors facilitate the implementation and have an influence on the use and compliance with CPGs. To increase support for and willingness to use the CPG, it appears important to involve all staffs in the implementation process as well as to follow up and give feedback continuously to staff and management. It seems necessary to evaluate the process to supervise compliance with CPGs and to balance priorities and costs. Evaluation can also demonstrate importance of the application.

PMID: 20070594 [PubMed - as supplied by publisher]

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A guideline-based decision support for pharmacological treatment can improve the quality of hyperlipidemia management.

Comput Methods Programs Biomed. 2010 Jan 8;

Authors: Chen C, Chen K, Hsu CY, Chiu WT, Li YC

INTRODUCTION: The Institute of Medicine has identified both Computerized Physician Order Entry (CPOE) and Electronic Prescription (EP) as key in reducing medication errors and improving safety. Many computerized clinical decision support systems (CDSSs) improve practitioner performance. However, the development of CDSSs involves a long cycle time that makes it difficult to apply in a wider scope. METHODS: In this study, we integrated the hyperlipidemia treatment guideline ATP III (Adult Treatment Panel III) in a CPOE of a medical center. The first 200 consecutive patients followed up more than 1 year were recorded for analysis. RESULTS: Our study revealed that 130 (65%) patients reached the LDL-C (low density lipoprotein-cholesterol) goal in 1 year. For those who with CDSS finished, 74% reached the LDL-C goal. For those who with CDSS exited, 57% reached the LDL-C goal. The odds ratio is 2.1 (1.2, 3.8) (p=0.022), which means for those who with CDSS finished can have 2 times of chance to reach the LDL-C goal. The mean of days to attain the LDL-C goal level after initiation of antihyperlipidemia therapy was 175+/-98 days. 11,806 prescribing records from 8023 patients were collected for analyzing the reasons of prematurely exiting the CDSS. The most frequent reason for exiting the system is "too busy to use". CONCLUSION: We conclude that a CPOE with CDSS integrated may let more hyperlipidemia patients reach the LDL-C goal. However, data also showed the total prescribing time may increase. The results of a preliminary evaluation are presented to illustrate that the CDSSs can improve the quality of hyperlipidemia management.

PMID: 20061045 [PubMed - as supplied by publisher]

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Antipsychotic Polypharmacy in Outpatients at Birch Hill Hospital: Incidence and Adherence to Guidelines.

J Clin Pharmacol. 2010 Jan 7;

Authors: Ranceva N, Ashraf W, Odelola D

The purpose of this article is to determine prescribing rates and adherence to guidelines with regard to antipsychotic polypharmacy, high-dose prescribing, and sedative use in an outpatient population. A prospective case-note audit involving 250 consecutive attendees of an outpatient clinic was carried out. Data were analyzed using descriptive statistical methods. Differences between the groups were estimated using t test and chi(2) where applicable. Results showed that the rate of polypharmacy was 17.4%. Reasons for polypharmacy were documented in 53% of cases. High-dose antipsychotics were used in 2.5% of the monotherapy group and in 38% of the polypharmacy group. An ECG was done in 35% of patients on high-dose antipsychotic therapy. In the monotherapy group, 6.2% versus 26.5% in the polypharmacy group of patients were on at least 1 sedative or hypnotic (odds ratio [OR], 5.47; 95% confidence interval [CI], 2.02-14.82; P < .001). Forty-two percent of patients prescribed sedatives had schizophrenia spectrum disorders, and none of the patients were diagnosed with anxiety disorders. The current study confirms that despite repeated recommendations against the practice, polypharmacy rates remain consistent at the 20% level. Thorough documentation, calculating the total antipsychotic dose, and obtaining an ECG would constitute good practice.

PMID: 20056801 [PubMed - as supplied by publisher]

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