Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines.

J Neurotrauma. 2011 Aug;28(8):1341-61

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

Abstract
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 - in process]

Evaluation of the dissemination and implementation of pressure ulcer guidelines in Dutch nursing homes.

J Eval Clin Pract. 2011 Aug;17(4):705-12

Authors: Meesterberends E, Halfens RJ, Lohrmann C, Schols JM, de Wit R

Abstract
Rationale, aims and objectives? Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes. Methods? Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons. Results? The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication. Conclusions? The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines.

PMID: 20586840 [PubMed - in process]

Implementing guidelines into clinical practice: what is the value?

J Eval Clin Pract. 2011 Aug;17(4):606-614

Authors: Hoomans T, Ament AJ, Evers SM, Severens JL

Abstract
Rationale and objective? In budget-constrained health systems, decision makers need to consider both the costs and effects of introducing and actively implementing clinical guidance. We aim to demonstrate how, as an alternative to conventional methods, a total net benefit approach to economic evaluation can be used to inform decision making about guidelines and specific implementation strategies, like education or financial incentives. Methods? Aside from providing more detail on the decision framework, we describe how to collect and analyse the relevant data for calculating the total net benefit of guideline use and the value of implementation. We illustrate the process of decision analysis for a stylized example on improving diabetes care in the UK. For the analysis, economic evidence on intensified glycemic control and that on audit and feedback to promote control is combined with information on diabetes practice. Results? Our illustration demonstrates that the total net benefit of guideline use and the value of implementation can vary substantially, depending on the clinical intervention chosen, the health system being studied and the specific implementation strategies. This also holds for the threshold value for cost-effectiveness, the duration of guideline usage or validity, the size of the patient population served, and the trends and ceiling rates in the implementation of clinical guidance. Conclusions? In comparison with conventional methods for health economic evaluation, a total net benefit approach allows for the explicit consideration of the current (or future) use of guidelines or guideline recommendations, the cost of implementation and the scope of clinical practice. Decisions made on the basis of the total net benefit of all plausible combinations of clinical guidance and implementation strategies provide optimal patient care and an efficient use of resources.

PMID: 21029273 [PubMed - as supplied by publisher]

Current Assessment of the Effects of Environmental Chemicals on the Mammary Gland in Guideline Rodent Studies by the U.S. Environmental Protection Agency (U.S. EPA), Organisation for Economic Co-operation and Development (OECD), and National Toxicology Program (NTP).

Environ Health Perspect. 2011 Aug;119(8):1047-52

Authors: Makris SL

Abstract
Background: Evaluation of the structural and/or functional integrity of the mammary gland (MG) across life stages is integral to the assessment of developmental, reproductive, and carcinogenic risk for environmental chemicals.Objectives: In this commentary I characterize MG assessment recommended in U.S. Environmental Protection Agency, Organisation for Economic Co-operation and Development, and National Toxicology Program guideline toxicology study protocols and identify any information gaps for the evaluation of MG development, structure, and function.Discussion: Several data gaps, issues, and challenges were identified. Current guidelines that include a lactation phase do not provide specific recommendations to record observations on maternal or offspring lactation or nursing behavior. In guideline studies, the assessment of MG toxicity often relies upon indirect, nonspecific, or surrogate end points, and information that could be useful in the interpretation of these data (e.g., mode of action or toxicokinetics) is often unavailable. Most guideline studies designed to assess general organ toxicity do not expose test animals during sensitive stages of MG development; histopathological evaluation of the developing MG is not routinely conducted; and evaluation of MG tissue for both sexes is inconsistently recommended.Conclusions: I propose the following general recommendations to enhance MG assessment in guideline toxicology studies: a) inclusion of more specific criteria for the evaluation of MG end points in guideline language, b) inclusion of histopathological evaluation of MG development (using whole-mount techniques) in existing or new guideline protocols that include offspring with perinatal and/or pubertal treatment, c) incorporation of perinatal exposures into rodent subchronic and carcinogenicity assays, and d) expansion of the histopathological evaluation of male MG tissue.

PMID: 21118785 [PubMed - in process]

Development and use of reporting guidelines for assessing the quality of validation studies of health administrative data.

J Clin Epidemiol. 2011 Aug;64(8):821-9

Authors: Benchimol EI, Manuel DG, To T, Griffiths AM, Rabeneck L, Guttmann A

Abstract
BACKGROUND AND OBJECTIVES: Validation of health administrative data for identifying patients with different health states (diseases and conditions) is a research priority, but no guidelines exist for ensuring quality. We created reporting guidelines for studies validating administrative data identification algorithms and used them to assess the quality of reporting of validation studies in the literature.
METHODS: Using Standards for Reporting of Diagnostic accuracy (STARD) criteria as a guide, we created a 40-item checklist of items with which identification accuracy studies should be reported. A systematic review identified studies that validated identification algorithms using administrative data. We used the checklist to assess the quality of reporting.
RESULTS: In 271 included articles, goals and data sources were well reported but few reported four or more statistical estimates of accuracy (36.9%). In 65.9% of studies reporting positive predictive value (PPV)/negative predictive value (NPV), the prevalence of disease in the validation cohort was higher than in the administrative data, potentially falsely elevating predictive values. Subgroup accuracy (53.1%) and 95% confidence intervals for accuracy measures (35.8%) were also underreported.
CONCLUSIONS: The quality of studies validating health states in the administrative data varies, with significant deficits in reporting of markers of diagnostic accuracy, including the appropriate estimation of PPV and NPV. These omissions could lead to misclassification bias and incorrect estimation of incidence and health services utilization rates. Use of a reporting checklist, such as the one created for this study by modifying the STARD criteria, could improve the quality of reporting of validation studies, allowing for accurate application of algorithms, and interpretation of research using health administrative data.

PMID: 21194889 [PubMed - indexed for MEDLINE]

Evaluating clinical practice guidelines developed for the management of thyroid nodules and thyroid cancers and assessing the reliability and validity of the AGREE instrument.

J Eval Clin Pract. 2011 Aug;17(4):729-736

Authors: Irani S, Rashidian A, Yousefi-Nooraie R, Soltani A

Abstract
Objectives? We assessed the quality of a sample of clinical guidelines for thyroid nodules and thyroid cancers, using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. We also evaluated the reliability and validity of the AGREE instrument and summarized the key recommendations of the appraised guidelines. Methods? Twenty-six clinical researchers and endocrinologists who had been trained in the principles of developing clinical guidelines and using the AGREE instrument participated in the study and appraised the guidelines. Clinical guidelines selected via a systematic search were assessed, each by eight participants. We compared the AGREE domain scores of the guidelines, and compared the participants’ scores before and after group discussions. We used Cronbach’s alpha, and intraclass correlation coefficients to assess the reliability, and the Spearman’s rho to assess the correlation between the overall assessment and other variables. Results? Seven guidelines were included in the study. ‘Scope and purpose’ and ‘clarity and presentation’ achieved the highest domain scores. ‘Applicability’ received the lowest domain scores and reliability coefficients. ‘Rigor of development’ and ‘clarity and presentation’ obtained the highest correlations with overall assessment scores. There was a significant relationship between the overall assessment score and the numbers of algorithms, tables and figures in the guidelines. Conclusions? We identified three clinical guidelines that obtained high overall assessment scores and were recommended for use in practice. Our findings have important implications for those developing clinical guidelines, especially as clarity and presentation significantly influenced the participants’ assessment of the guidelines. The developers should ensure that the recommendations are presented clearly and unambiguously, and flowcharts, algorithms and other tools are developed to help the users in applying the recommendations into practice. The optimal number of appraisers for each guideline is four. Further work is needed to improve the ‘applicability’ domain of the AGREE.

PMID: 21223456 [PubMed - as supplied by publisher]

Adherence to treatment guidelines and long-term survival in hospitalized patients with chronic obstructive pulmonary disease.

J Eval Clin Pract. 2011 Aug;17(4):737-743

Authors: Sarc I, Jeric T, Ziherl K, Suskovic S, Kosnik M, Anker SD, Lainscak M

Abstract
Rationale and aims? Adherence to treatment guidelines in chronic obstructive pulmonary disease (COPD) has been shown to be less than optimal over the COPD continuum. This retrospective study aimed to assess the implementation of COPD guidelines and potential association with long-term mortality in patients with COPD. Methods? All consecutive patient discharges in the period of February 2002-June 2007 from the University Clinic of Pulmonary and Allergic Diseases Golnik, Slovenia, were screened for a primary discharge diagnosis of COPD. Results? Data on 1185 patients (mean age 70?±?9 years, 72% men, 64% GOLD stage III/IV) were analysed. In the discharge letters 62% of patients had three or more drugs prescribed; 3% had no regular prescription. Most patients were discharged with short-acting (91%) and long-acting ?2-agonists (LABAs, 65%) and inhaled corticosteroids (61%), and 23% received long-term oxygen therapy. Prescription rates of LABAs, tiotropium and inhaled corticosteroids increased over the disease continuum (P?< ?0.001). In total, 48% of patients died during a median follow-up of 1149 days. Deceased patients had been less often treated with LABAs, inhaled corticosteroids and tiotropium. In multivariate Cox proportional-hazards analysis, advanced age, current smoking status, lower body mass index, longer hospital stay and cancer were associated with higher mortality (P?

PMID: 21223458 [PubMed - as supplied by publisher]

Stratifying risk in chronic kidney disease: an observational study of UK guidelines for measuring total proteinuria and albuminuria.

QJM. 2011 Aug;104(8):663-70

Authors: Methven S, Traynor JP, Hair MD, O’Reilly DS, Deighan CJ, Macgregor MS

Abstract
BACKGROUND: Proteinuria predicts poor renal and cardiovascular outcomes. Some guidelines recommend measuring proteinuria using albumin:creatinine ratio (ACR), while others recommend total protein:creatinine ratio (TPCR).
AIM: To compare renal outcomes and mortality in the populations identified by these different recommendations.
DESIGN: Retrospective longitudinal cohort study.
METHODS: Baseline ACR and TPCR measurements were obtained from 5586 patients with chronic kidney disease (CKD) attending a Scottish hospital nephrology clinic. The cohort was divided into three groups with concordant results by ACR and TPCR (no proteinuria; low proteinuria; significant proteinuria) and one group with discordant results (significant proteinuria with TPCR, but not ACR). Outcomes were assessed using Kaplan-Meier plots and Cox proportional hazards models.
RESULTS: Median follow-up was 3.5 years [interquartile range (IQR) 2.1-6.0]; 844 (15%) died at 3.0 years (IQR 1.8-4.7) and 468 (8%) started renal replacement therapy (RRT) at 1.7 years (IQR 0.6-3.4). Proteinuria was associated with a substantially increased risk of RRT and death. Patients with significant proteinuria by TPCR, but not ACR (n?=?231) had high renal risk, and the highest all-cause mortality (log-rank P?< ?0.001). With multivariate analysis the risk fell below those with significant proteinuria with concordant results by ACR and TPCR but remained considerably higher than those without significant proteinuria.

CONCLUSION: Proteinuria screening with TPCR identifies an additional 16% of patients with significant proteinuria, not identified using ACR. This subgroup has high renal risk, and high risk of all-cause mortality and therefore warrant identification. Guideline recommendations on proteinuria screening in CKD should be reconsidered.

PMID: 21382924 [PubMed - in process]

Hormone therapy in perimenopause and postmenopause (HT). Interdisciplinary S3 Guideline, Association of the Scientific Medical Societies in Germany AWMF 015/062-short version.

Arch Gynecol Obstet. 2011 Aug;284(2):343-55

Authors: Ortmann O, Dören M, Windler E,

Abstract
This short version of the interdisciplinary S3 guideline on hormone therapy in peri- and postmenopause (HT) is intended as a decision-making instrument for physicians and women considering HT. It is designed to assist daily practice. This short version summarises the long version that contains detailed information about the development of the guideline, particularly about establishing the evidence levels. The statements and recommendations, quoted completely, are marked with the relevant levels of evidence (LoE) and grades of recommendation. The classification system from the Centre for Evidence-based Medicine in Oxford was used in this guideline (see “Attachment”).

PMID: 21431845 [PubMed - in process]

Guidelines for the development and validation of new potency assays for the evaluation of umbilical cord blood.

Cytotherapy. 2011 Aug;13(7):848-55

Authors: Spellman S, Hurley CK, Brady C, Phillips-Johnson L, Chow R, Laughlin M, McMannis J, Reems JA, Regan D, Rubinstein P, Kurtzberg J

Abstract
Abstract The following commentary was developed by the National Marrow Donor Program Cord Blood Advisory Group and is intended to provide an overview of umbilical cord blood (UCB) processing, summarize the current state of potency assays used to characterize UCB, and define limitations of the assays and future needs of the cord blood banking and transplant community. The UCB banking industry is eager to participate in the development of standardized assays to uniformly characterize cellular therapy products that are manufactured in a variety of ways. This paper describes the desired qualities of these assays and how the industry proposes to co-operate with developers to bring relevant assays to market. To that end, the National Marrow Donor Program (NMDP) Cord Blood Bank Network is available to serve as a resource for UCB testing material, research and development consulting, and product/assay testing in an accredited UCB manufacturing environment.

PMID: 21449685 [PubMed - in process]