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Optimizing the Management of Atrial Fibrillation: Focus on Current Guidelines and the Impact of New Agents on Future Recommendations.

J Cardiovasc Pharmacol Ther. 2010 Jun 18;

Authors: Naccarelli GV, Curtis AB

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in everyday clinical practice. It affects approximately 2.3 million individuals in the United States, and the prevalence is expected to increase approximately 2.5-fold over the next 40 years. Atrial fibrillation accounts for more than 2 million hospitalizations each year and contributes to nearly 67 000 deaths. Our understanding of the pathophysiology of AF has increased dramatically over the past few decades. Recent treatment guidelines have heightened our awareness of the challenges involved in the treatment of AF and provided useful recommendations for its diagnosis and management. Because AF is usually associated with multiple comorbid conditions, greater emphasis must be placed on individualizing treatment. This review focuses on current treatment guidelines for patients with AF, assessing the benefits and shortcomings of current pharmacologic options and discussing new agents and trials that may provide better opportunities to improve and individualize patient management.

PMID: 20562374 [PubMed - as supplied by publisher]

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Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines.

J Neurotrauma. 2010 Jun 16;

Authors: Ahn H, Singh J, Nathens A, Macdonald RD, Travers A, Tallon J, Fehlings M, Yee A

Abstract An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

PMID: 20175667 [PubMed - as supplied by publisher]

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Immediate loading in the maxillary arch. Evidence based guidelines to improve success rates. A Review.

J Oral Implantol. 2010 Jun 16;

Authors: Chung S, McCullagh A, Irinakis T

Abstract The reliability of immediately loaded dental implants in the mandible has prompted many to investigate its application in the maxilla. Although the body of literature is growing, the long term survivability of immediate loading in the maxilla is still pending. This review of literature investigates the status of the immediate loading of dental implants in the maxilla to determine its predictability as a treatment option for partial and complete maxillary edentulism. The current terminology in the field is first summarized. Subsequently, the rationale and advantages of immediate loading in the maxilla are reviewed and the relationships between immediate loading and osseointegration, primary stability, implant design, micromotion, immediate implant placement and bone character are explored. The importance of a prosthodontically driven implant treatment plan emphasizing the role splinting, a high precision and passively fitting implant restoration and reduced micromotion under function are summarized. The reliability and predictability of immediately loaded implants as a treatment option is proposed and recommended guidelines for the successful delivery of immediately loaded implants in the maxilla are presented.

PMID: 20553124 [PubMed - as supplied by publisher]

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Evaluating the effectiveness of an educational and feedback intervention aimed at improving consideration of sex differences in guideline development.

Qual Saf Health Care. 2010 Jun 16;

Authors: Keuken DG, Haafkens JA, Mohrs J, Klazinga NS, Bindels PJ

Objectives To investigate the effect of an educational and feedback intervention to enhance consideration of sex differences in clinical guideline development. Design Preintervention and postintervention questionnaires in intervention and control groups. Content analysis of intervention guidelines and former versions. Setting Guideline consultants, working-group members and guideline documents of two Dutch guideline-developing organisations. Main outcome measures Attitudes of guideline developers concerning the importance of considering sex differences and the number of the sex-specific statements in the contents of guideline documents. Results The attitude of the intervention group did not change significantly relative to the control group. Consideration of sex-related factors within the guidelines increased relative to available previous versions. Conclusion Education and expert feedback may increase consideration of sex differences in guidelines. Further efforts are needed to implement and test these interventions.

PMID: 20554574 [PubMed - as supplied by publisher]

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Outpatient cardiology practices with advanced practice nurses and physician assistants provide similar delivery of recommended therapies (findings from IMPROVE HF).

Am J Cardiol. 2010 Jun 15;105(12):1773-9

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

National guidelines recommend a team model of care to facilitate adherence to evidence-based practices; however, previous studies suggesting benefit may have limited generalizability. The aim of this study was to examine the influence of advanced practice nurse (APN) and physician assistant (PA) staffing on the delivery of guideline-recommended therapies for outpatients with heart failure (HF). The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic HF and left ventricular ejection fractions < or =35%. Adherence to guideline-recommended HF therapies was recorded, and the presence of APN and PA staffing was assessed by survey. Multivariate models identified contributions to the delivery of guideline-recommended HF therapies. Of cardiology outpatient practices, 66.0% had APNs and PAs. Practices with 0, >0 to <2, and > or =2.0 APN and PA staffing had similar adherence to the 7 guideline-recommended HF therapies. After adjustment, staffing with > or =2 APNs or PAs was associated with greater conformity with 2 of 7 measures (implantable cardioverter-defibrillator therapy and delivery of HF education, p < or =0.01 for both) and similar conformity to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, beta-blocker therapy, aldosterone antagonist therapy, anticoagulation for atrial fibrillation, and cardiac resynchronization therapy. In conclusion, staffing with APNs and PAs varied in cardiology outpatient practices. Compared to no APNs or PAs, > or =2.0 APNs or PAs per cardiology practice was associated with the greater use of implantable cardioverter-defibrillator therapy and delivery of HF education and equivalent use of drug and cardiac resynchronization therapies.

PMID: 20538129 [PubMed - indexed for MEDLINE]

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Guidelines on perioperative cardiovascular evaluation.

Ann Intern Med. 2010 Jun 15;152(12):824; author reply 824-5

Authors: Brett AS

PMID: 20547913 [PubMed - indexed for MEDLINE]

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Association between guideline adherence and clinical outcome for patients referred for diagnostic breast imaging.

Qual Saf Health Care. 2010 Jun 15;

Authors: Vercauteren LD, Kessels AG, van der Weijden T, Severens JL, van Engelshoven JM, Flobbe K

OBJECTIVE: To assess the adherence to a guideline for additional breast ultrasonography in a cross-sectional survey among hospitals in The Netherlands. Furthermore, consequences of current practice non-adherence for the patient outcome of diagnostic breast imaging were studied. METHODS: Current practice was compared with a guideline made up of three recommendations for the use of ultrasonography after mammography and three recommendations for not using ultrasonography. All patients referred for mammography to the radiology departments of the participating hospitals during 2 months in 2004 were eligible for the study. No data on the gold standard for breast cancer were analysed, but clinical consequences were estimated by using a probability model based on the data of a former prospective clinical study. RESULTS: In total, 17 of the 66 hospitals approached were participating in the study. Of the 13 694 patients assessed for eligibility, 6457 were included. High adherence rates (81-97%, mean 94%) were observed for the recommendations, which indicate additional ultrasonography, whereas lower adherence rates (68-94%, mean 83%) were seen for the recommendations which do not advise additional ultrasonography. Overall, in all included hospitals, non-adherence would result in 27.2 false-positive and 1.1 false-negative imaging results. CONCLUSION: Current daily practice of diagnostic breast imaging in the hospitals in this survey corresponds to a great extent to the guideline proposed. Non-adherence in current practice results in a relatively small number of false-positive and false-negative imaging results.

PMID: 20551187 [PubMed - as supplied by publisher]

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High-risk patients with hematuria are not evaluated according to guideline recommendations.

Cancer. 2010 Jun 15;116(12):2954-9

Authors: Elias K, Svatek RS, Gupta S, Ho R, Lotan Y

BACKGROUND: To determine whether high-risk patients with hematuria receive evaluation according to guideline recommendations. METHODS: We recently performed a screening study for bladder cancer using a urine-based tumor marker in 1502 subjects at high risk based on aged > or = 50 years, > or = 10-year smoking history, and/or a 15-year or more environmental exposure. We evaluated use of urinalysis (UA) within 3 years preceding the screening study. Chart review was performed to determine if this subset with microhematuria received any additional evaluation. RESULTS: Of 1502 study participants, routine urinalysis was performed in 73.2% and 164 (14.9%) subjects had documented hematuria (>3 red blood cells / high-power field) before inclusion. Of these, 42.1% had no further evaluation. Additional testing included repeat urinalysis (36%), urine culture (15.2%), cytology (10.4%), imaging (22.6% overall: 15.9% computed tomography, 4.3% intravenous pyelography; 2.4% magnetic resonance imaging), and cystoscopy (12.8%). Three subjects with microscopic hematuria (2%) were subsequently found to have bladder cancer during the screening study but were not referred for evaluation based on their hematuria. The source of hematuria was unknown in 65%, infection in 22%, benign prostatic enlargement in 10%, and renal stone disease in 4%, but these results are based on incomplete evaluation since only 12.8% underwent cystoscopy. CONCLUSIONS: Subjects at high risk for bladder cancer based on > or = 10 years of smoking or environmental exposure with microscopic hematuria are rarely evaluated thoroughly and only 12.8% were referred for urologic evaluation. Further studies are needed to evaluate both the utilization and effectiveness of guidelines for hematuria.

PMID: 20564400 [PubMed - indexed for MEDLINE]

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[Opinions of general practitioners, psychiatrists and psychologists on the clinical practice guidelines for depression.]

Aten Primaria. 2010 Jun 14;

Authors: Fernandez Sanchez A, Sanchez-Carracedo D, Navarro-Rubio MD, Pinto-Meza A, Moreno-Kastner B

AIM: To explore the views on clinical practice guidelines (CPG) of general practitioners (GP), psychiatrists, and psychologists. DESIGN: Descriptive-exploratory qualitative study based on semi-structured individual and group interviews. SETTING: Public primary health care and mental health centres in Barcelona, Sabadell, Cornellà de Llobregat and Gavà. PARTICIPANTS AND CONTEXT: A total of 31 health professionals (10GPs, 11 psychiatrists, and 10 psychologists) interviewed at their work place or at the research unit between October 2007 and June 2008. METHOD: Convenience sample. Participants were heterogeneous as regards sex, age, experience and workplace. Interviews were recoded and transcribed. Content analysis. Triangulation between techniques and results comparisons with participants was carried out as quality control. RESULTS: The main advantages of CPGs were that they helped in decision making and gave security. On the other hand, participants were sceptical about the objectivity of GPC and considered that recommendations could not be applied to their individual patients. Additionally, they perceived CPG as inflexible. At the time of the study, GPs did not know of any CPG for depression. Specialists knew several CPGs but they did not use them as they prioritise their own experience. CONCLUSIONS: There are some erroneous ideas about what a CPG is. If we want to implement CPGs, it is important to carry out some previous work presenting what a CPG is, what it is not and when it could be useful.

PMID: 20554352 [PubMed - as supplied by publisher]

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Screening for overt diabetes by oral glucose tolerance test: Stratification by fasting blood glucose and patients' age improve practicability of guidelines in cardiological routine.

Int J Cardiol. 2010 Jun 11;

Authors: Kempf K, Füth R, Dinh W, Bansemir L, Köhler T, Bufe A, Scheffold T, Standl E, Martin S, Lankisch M

BACKGROUND/OBJECTIVES: Guidelines recommend screening all patients with cardiovascular disease by oral glucose tolerance test (OGTT). Due to its time-consuming protocol, costs and overall inconvenience performance of OGTT is limited in cardiological routine. Thus, we aimed to identify easily available parameters that could help to reduce the numbers of OGTT needed. METHODS: OGTTs (n=1215) were performed in all patients without known type 2 diabetes mellitus (T2DM) that were submitted to the heart center Wuppertal with known or suspected coronary artery disease for an elective coronary angiography from January to October 2007. RESULTS: 31.4% had normal glucose tolerance; prediabetes was present in 50.7%, whereas 17.9% were newly diagnosed with T2DM. Thus, 998 OGTTs did not result in the new diagnosis of so far undiagnosed T2DM. Multiple logistic regression and receiver operated characteristic analyses demonstrated that fasting blood glucose (FBG)>/=90mg/dl and age>/=55years were predictive for so far undiagnosed T2DM. Considering these two parameters 81.1% (=sensitivity) of so far undiagnosed T2DM patients would have been identified (specificity=63.4%) and the number of OGTTs could have been reduced from 1215 to 541. CONCLUSIONS: About 70% of patients were newly diagnosed with impaired glucose metabolism. FBG>/=90mg/dl and age>/=55years were predictive for so far undiagnosed T2DM and OGTTs could be reduced by 55.5%. This should alleviate the implementation of the current guidelines in daily cardiological practice.

PMID: 20542339 [PubMed - as supplied by publisher]

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