[What is new in the 2009 ESC guidelines?]

Herzschrittmacherther Elektrophysiol. 2011 Apr 28;

Authors: von Scheidt W, Seidl K

The 2009 ESC guideline emphasizes active risk stratification and the diagnostic strategy of prolonged ECG monitoring using an implantable loop recorder. The initial evaluation aims at establishing a prima vista diagnosis or at least a diagnostic hypothesis and risk stratification according to ECG criteria and clinical findings. Carotid sinus massage as a diagnostic procedure remains controversial. Electrophysiological study for evaluation of suspected arrhythmogenic syncope is of decreasing relevance. The loop recorder enables documentation of the rhythm during a subsequent syncope. Neurological work-up is not routinely recommended. A standardized evaluation minimizes the rate of unexplained syncopes. Therapeutic decisions include ICD or pacemaker, as indicated in cases of arrhythmogenic syncope or carotid sinus syncope, and mostly general measures in case of other reflex syncopes.

PMID: 21523455 [PubMed - as supplied by publisher]

The use of microbead-based spoligotyping for Mycobacterium tuberculosis complex to evaluate the quality of the conventional method : Providing guidelines for Quality Assurance when working on membranes.

BMC Infect Dis. 2011 Apr 28;11(1):110

Authors: Abadia E, Zhang J, Ritacco V, Kremer K, Ruimy R, Rigouts L, Gomes HM, Ribeiro Elias A, Fauville-Dufaux M, Stoffels K, Rasolofo-Razanamparany V, Garcia de Viedma D, Herranz M, Al-Hajoj S, Rastogi N, Garzelli C, Tortoli E, Suffys PN, van Soolingen D, Refregier G, Sola C

ABSTRACT: BACKGROUND: The classical spoligotyping technique, relying on membrane reverse line-blot hybridization of the spacers of the Mycobacterium tuberculosis CRISPR locus, is used world-wide (598 references in Pubmed on April 8th, 2011). However, until now no inter-laboratory quality control study had been undertaken to validate this technique. We analyzed the quality of membrane-based spoligotyping by comparing it to the recently introduced and highly robust microbead-based spoligotyping. Nine hundred and twenty-seven isolates were analyzed totaling 39,861 data points. Samples were received from 11 international laboratories with a worldwide distribution. METHODS: The high-throughput microbead- based Spoligotyping was performed on CTAB and thermolyzate DNA extracted from isolated Mycobacterium tuberculosis complex (MTC) strains coming from the genotyping participating centers. Information regarding how the classical Spoligotyping method was performed by center was available. Genotype discriminatory analyses were carried out by comparing the spoligotypes obtained by both methods. The non parametric U-Mann Whitney homogeneity test and the Spearman rank correlation tests were performed to validate the observed results. RESULTS: Seven out of the 11 laboratories (63 %), perfectly typed more than 90% of isolates, 3 scored between 80-90% and a single center was under 80% reaching 51% concordance only. However, this was mainly due to discordance in a single spacer, likely having a non-functional probe on the membrane used. The centers using thermolyzate DNA performed as well as centers using the more extended CTAB extraction procedure. Few centers shared the same problematic spacers and these problematic spacers were scattered over the whole CRISPR locus (Mostly spacers 15, 14, 18, 37, 39, 40). CONCLUSIONS: We confirm that classical spoligotyping is a robust method with generally a high reliability in most centers. The applied DNA extraction procedure (CTAB or thermolyzate) did not affect the results in this study. However performance was center-dependent, suggesting that training is a key component in quality assurance of spoligotyping. Overall, no particular spacer yielded a higher degree of deviating results, suggesting that errors occur randomly either in the process of re-using membranes, or during the reading of the results and transferring of data from the film to a digital file. Last, the performance of the microbead-based method was excellent as previously shown by Cowan et al. (J. Clin. Microbiol. 2004) and Zhang et al. (J. Med. Microbiol. 2009), and demonstrated the proper detection of spacer 15 that is known to occasionally give weak signals in the classical spoligotyping.

PMID: 21527037 [PubMed - as supplied by publisher]

Long-term adherence to a local guideline on postoperative body temperature measurement: mixed methods analysis.

J Eval Clin Pract. 2011 Apr 26;

Authors: Storm-Versloot MN, Knops AM, Ubbink DT, Goossens A, Legemate DA, Vermeulen H

Aim? To find out whether a successful multifaceted implementation approach of a local evidence-based guideline on postoperative body temperature measurements (BTM) was persistent over time, and which factors influenced long-term adherence. Methods? Mixed methods analysis. Patient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus group meetings for nurses and a plenary meeting with an interactive questionnaire for doctors. Results? Records from 102 surgical patients were studied, totalling 1226 BTM. According to the guideline, an indication for BTM was present in 55% (679/1226). Actually, BTM were taken in 60% (736/1226), of which 55% (403/736) was in accordance with the guideline. The overall adherence rate to the guideline was 50% (617/1226). Belief in the advantages of the guideline and strong staff support appeared to facilitate long-term adherence. Barriers were, the controversial nature of the guideline, the lack of self-efficacy among nurses and doctors as to clinical judgement to identify an infection when refraining from BTM, and a lack of management and staff doctor support. Furthermore, newly appointed nurses and doctors were trained to measure BTM during their initial medical or nursing education, which was in contradiction with the guideline. Conclusions? A multifaceted implementation strategy is not sufficient to maintain long-term adherence. To ensure long-term adherence, especially of controversial guidelines, adherence should be monitored and reported regularly over time. Strong staff support and leadership on all wards is crucial to maintain awareness. Medical and nursing curricula should include the pros and cons of taking BTM, combined with enhancing self-efficacy.

PMID: 21518400 [PubMed - as supplied by publisher]

A hospital site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria.

Implement Sci. 2011 Apr 22;6(1):41

Authors: Trautner BW, Kelly PA, Petersen N, Hysong S, Kell H, Liao KS, Patterson JE, Naik AD

ABSTRACT: BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. However, many cases treated as hospital-acquired CAUTI are actually asymptomatic bacteriuria (ABU). Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients, but there is a significant gap between these guidelines and clinical practice. Our objectives are (1) to evaluate the effectiveness of an audit and feedback intervention for increasing guideline-concordant care concerning catheter-associated ABU and (2) to measure improvements in healthcare providers’ knowledge of and attitudes toward the practice guidelines associated with the intervention. METHODS: The study uses a controlled pre/post design to test an intervention using audit and feedback of healthcare providers to improve their compliance with ABU guidelines. The intervention and the control sites are two VA hospitals. For objective 1 we will review medical records to measure the clinical outcomes of inappropriate screening for and treatment of catheter-associated ABU. For objective 2 we will survey providers’ knowledge and attitudes. Three phases of our protocol are proposed: the first 12-month phase will involve observation of the baseline incidence of inappropriate screening for and treatment of ABU at both sites. This surveillance for clinical outcomes will continue at both sites throughout the study. Phase 2 consists of 12 months of individualized audit and feedback at the intervention site and guidelines distribution at both sites. The third phase, also over 12 months, will provide unit-level feedback at the intervention site to assess sustainability. Healthcare providers at the intervention site during phase 2 and at both sites during phase 3 will complete pre/post surveys of awareness and familiarity (knowledge), as well as of acceptance and outcome expectancy (attitudes) regarding the relevant practice guidelines. DISCUSSION: Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease overdiagnosis of CAUTI and associated inappropriate antibiotic use. Our study will also provide information about how to maximize effectiveness of audit and feedback to achieve guideline adherence in the inpatient setting. Trial Registration: NCT01052545.

PMID: 21513539 [PubMed - as supplied by publisher]

Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists.

Thyroid. 2011 Apr 21;

Authors: Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN

Background: Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition. Methods: The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. Results: Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves’ hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves’ disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves’ ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis. Conclusions: One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

PMID: 21510801 [PubMed - as supplied by publisher]

Impact of Updated Institute of Medicine Guidelines on Prepregnancy Body Mass Index Categorization, Gestational Weight Gain Recommendations, and Needed Counseling.

J Womens Health (Larchmt). 2011 Apr 21;

Authors: Simas TA, Liao X, Garrison A, Sullivan GM, Howard AE, Hardy JR

Abstract Background: Our objective was to quantify how the 2009 revisions of the 1990 Institute of Medicine (IOM) gestational weight gain (GWG) guidelines change women’s body mass index (BMI) categorization and BMI-specific GWG adherence categories. The goal was to identify how provider counseling practices need to change on a population level. Methods: A retrospective review of automated labor and delivery records from a tertiary care hospital in Central Massachusetts was performed. The study cohort included women who delivered singleton, live birth gestations from from April 1, 2006, to September 30, 2009. Records missing weight, height, GWG, gestational age (GA), and/or GA <22 or >43 weeks were excluded. BMI groups and GWG adherence were categorized according to IOM 1990 and 2009 recommendations. Adherence analyses included full-term gestations only. Results: The cohort consisted of 11,688 women, mean age 28.9 (±6.1) years and mean parity 1.0 (±1.1). By 1990 recommendations, 10.1%, 52.5%, 14.1%, and 23.3% gravidas were low weight, normal weight, high weight, and obese; and 19.8%, 33.3%, and 46.9% were undergainers, appropriate gainers, and overgainers, respectively. By 2009 recommendations, 3.9%, 51.3%, 24.5%, and 20.3% gravidas were underweight, normal weight, overweight, and obese, and 16.7%, 30.8%, and 52.6% were undergainers, appropriate gainers, and overgainers, respectively. Differences in categorization by guideline year was significant for BMI category (p<0.0001) and GWG adherence (p<0.0001). Compared to 1990 guidelines, 16.7% of women were classified differently using 2009 guidelines, with fewer classified as underweight, normal weight, or obese and more as overweight; 17.1% of 1990 appropriate gainers would be classified as overgainers, given new guidelines. Conclusions: Changes in IOM GWG recommendations alter gravidas’ BMI categories and, thus, the recommended GWG. As the amount advised is associated with actual gain, accuracy is paramount. GWG is a modifiable parameter associated with immediate and long-term maternal/neonatal health outcomes, and counseling can have a significant public health impact and should involve BMI determination, followed by BMI-specific GWG recommendations in accordance with current guidelines.

PMID: 21510805 [PubMed - as supplied by publisher]

A Call to Action: Variability in Guidelines for Cardiac Evaluation before Renal Transplantation.

Clin J Am Soc Nephrol. 2011 Apr 21;

Authors: Friedman SE, Palac RT, Zlotnick DM, Chobanian MC, Costa SP

Summary Background and objectives Candidates for renal transplantation are at increased risk for complications related to cardiovascular disease; however, the optimal strategy to reduce this risk is not clear. The aim of this study was to evaluate the variability among existing guidelines for preoperative cardiac evaluation of renal transplant candidates. Design, setting, participants, & measurements A consecutive series of renal transplant candidates (n = 204) were identified, and four prominent preoperative cardiac evaluation guidelines, pertaining to this population, were retrospectively applied to determine the rate at which each guideline recommended cardiac stress testing. Results The rate of pretransplant cardiac stress testing would have ranged from 20 to 100% depending on which guideline was applied. The American Heart Association/American College of Cardiology (ACC/AHA) guideline resulted in the lowest rate of testing (20%). In our population, 178 study subjects underwent stress testing: 17 were found to have ischemia and 10 underwent revascularization. The ACC/AHA approach would have decreased the number of noninvasive tests from 178 to 39; it would have identified only 4 of the 10 patients who underwent revascularization. The three other guidelines (renal transplant-specific guidelines) recommended widespread pretransplant cardiac testing and thus identified nearly all patients who had ischemia on stress testing. Conclusions The ACC/AHA perioperative guideline may be inadequate for identifying renal transplant candidates with coronary disease; however, renal transplant-specific guidelines may provoke significant overtesting. An intermediate approach based on risk factors specific to the ESRD population may optimize detection of coronary disease and limit testing.

PMID: 21511835 [PubMed - as supplied by publisher]

Critical assessment of the European Association of Urology guideline indications for pelvic lymph node dissection at radical prostatectomy.

BJU Int. 2011 Apr 20;

Authors: Abdollah F, Sun M, Briganti A, Thuret R, Schmitges J, Gallina A, Suardi N, Capitanio U, Salonia A, Shariat SF, Perrotte P, Rigatti P, Montorsi F, Karakiewicz PI

Study Type – Prognosis (retrospective cohort) Level of Evidence?2b What’s known on the subject? and What does the study add? Lymphadenectomy is the most accurate lymph node staging procedure in patients with prostate cancer. We presented the first formal validation of the 2010 European Association of Urology guidelines for lymphadenectomy in prostate cancer patients. OBJECTIVE: •?To assess the 2010 European Association of Urology (EAU) guidelines for prostate cancer, which recommend a pelvic lymph node dissection (PLND) at radical prostatectomy in all individuals with a nomogram-predicted lymph node invasion (LNI) risk of >7%. PATIENTS AND METHODS: •?We focused on 1520 patients treated with radical prostatectomy and PLND, between 2006 and 2010, at a single European institution. We examined the ability of the EAU proposed threshold to correctly predict histologically confirmed LNI. Moreover, we tested the ability of a range of nomogram thresholds between 1 and 14% to correctly predict histologically confirmed LNI. Finally, we externally validated the EAU PLND guideline nomogram. RESULTS: •?Overall, 10.6% of patients had LNI. The use of the 7% limit would have allowed the avoidance of 49% of PLNDs, at the cost of missing 11% of patients with LNI. The use of thresholds of 6% and 8% would have allowed the avoidance of respectively 46% and 52% of PLNDs, at the cost of missing respectively 9% and 11% of patients with LNI. Overall, the accuracy of the EAU guideline nomogram according to the receiver operating characteristics derived area under curve was 81% CONCLUSION: •?Our observations indicate that the EAU guideline nomogram is highly accurate. The recommended threshold of 7%, above which a PLND should be performed, is associated with a favourable compromise between avoidable PLNDs and potentially missed LNI cases.

PMID: 21507189 [PubMed - as supplied by publisher]

Dietary treatments for epilepsy: Management guidelines for the general practitioner.

Epilepsy Behav. 2011 Apr 20;

Authors: Lee PR, Kossoff EH

As ketogenic diets become more frequently used as a standard treatment for epilepsy in children and adults, hospital and community neurologists, pediatricians, intensivists, general practitioners, and house officers will readily encounter patients who are receiving these dietary treatments. A growing body of evidence demonstrates that dietary therapies for epilepsy (classic ketogenic diet, medium-chain triglyceride diet, modified Atkins diet, and low-glycemic-index treatment) are highly effective, with approximately 30-60% of children overall having at least a 50% reduction in seizures after 6months of treatment. However, as would be true of any other medical anticonvulsant therapy, these treatments have known side effects and complications requiring recognition and timely action. In addition, the ketogenic diet is a significant intervention requiring rigorous daily adherence; not every family is willing or able to make the necessary commitment to this therapy. We provide herein a survey of the most common situations faced in both the inpatient and outpatient settings, including a discussion of triage and management based on our center’s experience as well as the recent 2009 International Consensus Guideline.

PMID: 21514240 [PubMed - as supplied by publisher]

Difficulties in the dissemination and implementation of clinical guidelines in government Neonatal Intensive Care Units in Brazil: how managers, medical and nursing, position themselves.

J Eval Clin Pract. 2011 Apr 19;

Authors: Magluta C, de Sousa Mendes Gomes MA, Wuillaume SM

Rationale, aims and objectives? Clinical guidelines are tools that systematize scientific evidence and help to achieve proper care. Several difficulties are reported regarding the effective use, such as the shortcomings in the level of knowledge and attitudes by the professionals, the service structure and the preferences appointed by patients. An analysis of these difficulties was the objective of this study in the context of government Neonatal Intensive Care Units (NICU) in Brazil. Method? A semi-structured survey was carried out with 53 managers (medical and nursing) of the 15 NICU in a convenient sample of two groups of government units in Brazil. The managers chose their answers from a list of difficulties to implement the guidelines based on the analytical model of Cabana and graded the difficulties found on a 5-point scale with no reference to quality. Results? Respondents have reported several difficulties with the following priority: lack of professionals to provide care, being perceived as more critical within the nursing and physiotherapy crews, minor participation of professionals in the discussion process and inadequate infrastructure. The lack of acquaintance with the guidelines by the professionals has been reported by few of the surveyed. Conclusion? These findings show some common ground to literature pointing the importance of adequate infrastructure. Managers showed a low valuation of both the level of knowledge and the professionals’ adhesion to the guidelines.

PMID: 21501340 [PubMed - as supplied by publisher]