The use of benzodiazepine monotherapy for major depression before and after implementation of guidelines for benzodiazepine use.

J Clin Pharm Ther. 2011 Oct;36(5):577-84

Authors: Lai IC, Wang MT, Wu BJ, Wu HH, Lian PW

Abstract
WHAT IS KNOWN AND OBJECTIVE: The Department of Health (DOH) in Taiwan issued the ‘Guidelines for Benzodiazepine Use in Sedation and Hypnosis’ in March 2004, which clearly stated that benzodiazepines (BZDs) should not be used alone for the treatment of depression. However, the extent to which clinicians comply with the BZD guidelines was not known. This study aimed to evaluate whether sole prescribing of BZDs for major depression decreased after the implementation of the BZD guidelines. METHODS: This was a retrospective longitudinal trend analysis by analyzing the Longitudinal Health Insurance Database (LHID) from September 2002 to September 2005. The LHID contains all claims data from a random sample of 1,000,000 beneficiaries of the universal National Health Insurance programme in Taiwan. The 3-year study period was divided equally into six periods, before and after the implementation of the guidelines respectively. For each period, the proportion of patients with major depression (ICD-9-CM code 296.2x, 296.3x) treated with BZDs without any concomitant antidepressant was calculated in order to conduct a trend analysis. RESULTS AND DISCUSSION: A total of 5463 prescriptions of BZDs solely used for major depression were observed in the entire study period. In more than 80% of the BZD prescriptions in which BZDs were used alone for major depression, they were prescribed at doses higher than one prescribed daily dose/defined daily dose and were supplied for more than 7 days. The number of outpatients with major depression ranged from 2137 to 3326 during the 12 periods. The proportion of depressed patients treated with BZDs alone per 3 months (i.e., the non-compliance rate) fluctuated from 6·7% to 9·4% before implementation of the guidelines, and from 8·0% to 9·4% after implementation, in outpatient settings. In addition, the guideline non-adherence rates in inpatient settings varied from 7·0% to 11·8% and from 7·8% to 12·6% before and after the implementation of the BZD guidelines respectively. Further trend analyses indicated that the implementation of the guidelines was not associated with a reduced rate of sole prescribing of BZDs for major depression in either inpatient (P = 0·083) or outpatient settings (P = 0·925). WHAT IS NEW AND CONCLUSION: The formulation and implementation of the BZD guidelines appear not to be associated with a reduced rate of sole prescribing of BZDs for major depression, and more comprehensive efforts are required.

PMID: 21062331 [PubMed - in process]

Evaluation of Japanese practice guidelines for newly diagnosed childhood idiopathic thrombocytopenic purpura.

Pediatr Int. 2011 Oct;53(5):701-5

Authors: Higashigawa M, Yamamoto T, Yoshino A, Nashida Y, Maji T, Fujiwara T, Inoue M

Abstract
Background:? Practice guidelines for childhood idiopathic thrombocytopenic purpura (ITP) were proposed in 1998 and 2004 in Japan. It is important to evaluate the feasibility and validity of the guidelines because the guidelines are based not on evidence but on opinion. Methods:? Records of 30 consecutive hospitalized patients aged 0-15 years (median, 3 years; 17 boys, 13 girls) were retrospectively reviewed. The feasibility and validity of the 2004 guidelines were evaluated by calculating an implementation rate, a response rate to first treatments, and a final clinical outcome. Results:? Deviation from the guidelines was found in two patients. Management of the other 28 patients followed the guidelines. The implementation rate was 93.3%. Twenty-one of the 28 eligible patients (75%) responded to the first treatment, whereas seven patients (25%) required additional treatment. In 23 patients (76.7%) platelet counts returned to normal within 6 months. Seven patients (23.3%) developed chronic conditions. All patients had no complications and achieved a platelet count >150?000/µL within 6 years. Conclusion:? The 2004 Japanese guidelines are feasible and valid for the management of newly diagnosed childhood ITP patients.

PMID: 21261788 [PubMed - in process]

Efficiency of bone density testing by dual-biphotonic X-rays absorptiometry for diagnosis of osteoporosis according to French guideline recommendations: The PRESAGE Study.

Joint Bone Spine. 2011 Oct;78(5):493-8

Authors: Guggenbuhl P, Dufour R, Liu-Léage S, Sapin H, Cortet B

Abstract
OBJECTIVES AND METHODS: Bone mineral density is a major risk factor of fracture. Its measurement is reimbursed by French national health insurance according to clinical criteria. In this multicentre cross-sectional observational study, we estimated the proportion of postmenopausal women with osteoporosis among those referred for a bone mineral density measurement. Risk factors for osteoporosis and therapeutic recommendations were described.
RESULTS: Six hundred and forty-six postmenopausal women were evaluated. Osteoporosis was diagnosed in 57.6%, osteopenia in 38.7% and a normal bone mineral density in 3.7%. The main risk factors for fracture were personal history of fracture (40%), family fracture (23%), smoking (15%) and glucocorticoids use (15%). Anti-osteoporosis drug was recommended for 93% of women with osteoporosis and for 45% of women with osteopenia. A logistic regression analysis showed that a T-score=-2.5 was the most important factor related to the treatment decision-making. Cluster analysis identified five types of women with different combinations of fracture risk factors. The percentage of postmenopausal women - 96.3% - referred for bone mineral density and for whom a treatment could be recommended had osteoporosis or osteopenia.
CONCLUSION: In spite of recommendations, the physician therapeutic decision-making was mainly based on the bone mineral density result.

PMID: 21367636 [PubMed - in process]

Identification of the most influential factors in the Norwegian guidelines for risk assessment of dispersion of contaminants from sediments.

Integr Environ Assess Manag. 2011 Oct;7(4):657-67

Authors: Saloranta TM, Ruus A, Borgå K

Abstract
The Norwegian guidelines for risk assessment of contaminated sediments are used to identify areas of concern where remediation may be needed to meet the governmental long-term goal of clean fjords and harbors along the Norwegian coastline. By a thorough sensitivity analysis, this study identifies the most influential factors and parameters for the Tier 2A model in this risk guideline, which are used to estimate fluxes of contaminants from sediments due to diffusion and bioturbation (F(diff)), resuspension caused by ship traffic (F(skipnorm)), and uptake and predation of benthic biota (F(org)). The sensitivity analysis is run for 36 different scenarios combining 3 different sizes of contaminated area, 3 harbor types, and 3 persistent organic pollutants, namely lindane (?-hexachlorocyclohexane), benzo[a]pyrene, and 2,2′,4,4′,5,5′-hexachlorobiphenyl (PCB-153), as well as the metal mercury (Hg). The most influential parameters vary from scenario to scenario, but generally 5 parameters appear to be particularly influential for the fluxes and transport estimated by the Tier 2A model: flux of organic carbon to sediment (OC(sed)), factor for increased diffusion due to bioturbation (a), sediment-water partitioning coefficient (K(d)), benthic biota-water bioconcentration factor (BCF(fisk)), and mass of resuspended fine sediment during arrival or departure of a ship (m(sed)). We also quantify which of the 3 fluxes (F(diff), F(skipnorm), and F(org)) dominate in the different scenarios. Our sensitivity analysis results can be used by authorities, problem owners, consultants, and environmental managers involved in contaminated sediment management to gain insight on the key processes and parameters and to focus their site-specific or laboratory-based measurement efforts on the key parameters and thus increase efficiency and reliability in the contaminated sediment risk assessment.

PMID: 21384542 [PubMed - in process]

Prognosis and Guideline-Adherent Antithrombotic Treatment in Patients With Atrial Fibrillation and Atrial Flutter: Implications of Undertreatment and Overtreatment in Real-life Clinical Practice; the Loire Valley Atrial Fibrillation Project.

Chest. 2011 Oct;140(4):911-7

Authors: Gorin L, Fauchier L, Nonin E, Charbonnier B, Babuty D, Lip GY

Abstract
BACKGROUND: In patients with atrial fibrillation (AF), adherence to guidelines for antithrombotic treatment is poorly followed, and undertreatment (or nonadherence with guidelines) is associated with a worse prognosis. The study objective was to evaluate whether this was also the case in a large contemporary series of unselected patients with AF in real-world clinical practice.
METHODS: All patients with AF or atrial flutter seen in our institution between 2000 and 2007 were identified in a database and followed up for mortality and stroke. Antithrombotic guideline adherence was assessed according to the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology guidelines.
RESULTS: We reviewed outcomes in 3,646 consecutive patients with AF or atrial flutter (aged 71 ± 14 years; mean CHADS(2) [congestive heart failure, hypertension, aged ? 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score, 1.5 ± 1.1). Antithrombotic treatment was in agreement with the guidelines in 53% of patients, whereas 31% were classified as undertreated and 16% as overtreated. Among other parameters, nonpermanent AF and atrial flutter were independently associated with an increased risk of undertreatment. After a follow-up of 953 ± 767 days (median, 771 days; interquartile range, 1,286 days), guideline adherence was associated with a lower risk of adverse events (death from all causes or stroke) compared with undertreatment (relative risk, 0.47; 95% CI, 0.40-0.55; P < .0001). Overtreatment was associated with a lower risk of adverse events compared with the guideline-adherent population (relative risk, 0.40; 95% CI, 0.28-0.58; P < .0001). Factors independently associated with increased risk of mortality or stroke were antithrombotic undertreatment, older age, heart failure, renal failure, diabetes, male sex, and previous history of stroke.

CONCLUSIONS: Guideline nonadherence and undertreatment with antithrombotic agents in unselected real-world patients with AF or atrial flutter are independently associated with a high risk of stroke and mortality.

PMID: 21436246 [PubMed - in process]

Physician adherence to the dyslipidemia guidelines is as challenging an issue as patient adherence.

Fam Pract. 2011 Oct;28(5):524-31

Authors: Vashitz G, Meyer J, Parmet Y, Henkin Y, Peleg R, Gilutz H

Abstract
BACKGROUND: A wide therapeutic gap exists between evidence-based guidelines and their practice in the primary care, which is primarily attributed to physician and patient adherence.
OBJECTIVE: This study aims to differentiate physician and patient adherence to dyslipidemia secondary prevention guidelines and various factors affecting it.
METHODS: A post hoc analysis of data collected by a prospective cluster randomized trial with 7041 patients diagnosed with clinical atherosclerosis requiring secondary prevention of dyslipidemia and 127 primary care physicians over an 18-month period. Adherence was measured by physicians’ and patients’ actions taken according to the guidelines and correlated using multivariate logistic regressions.
RESULTS: Physician adherence was 36.9% for lipid profile screening, 27.6% for pharmacotherapy up-titration and 21.0% for pharmacotherapy initiation. Physician adherence was positively correlated with frequent patient visits [odds ratios (OR = 1.304)], having more dyslipidemic patients (OR = 1.304) and treating immigrants (OR = 1.268). Patient adherence was 83.8%, 71.9% and 62.6% for medication up-titration, lipid profile screening and pharmacotherapy initiation, respectively. Patient adherence was affected by attending clinics with many dyslipidemic patients (OR = 1.542), being older (OR = 1.271) and being treated by a male physician (OR = 0.870).
CONCLUSIONS: We learn from this study that (i) physician non-adherence was a major cause for the failure to follow guidelines, (ii) pharmacotherapy initiation was the most challenging issue to tackle and (iii) greater adherence occurred mainly in high volume conditions (patients and visits). Practical implications are designated focus on metabolic condition prevention in primary care by cardiologists or primary care clinics specializing in metabolic conditions and the need to facilitate more frequent follow-up visits.

PMID: 21566005 [PubMed - in process]

Management of radiation dermatitis in patients receiving cetuximab and radiotherapy for locally advanced squamous cell carcinoma of the head and neck: proposals for a revised grading system and consensus management guidelines.

Ann Oncol. 2011 Oct;22(10):2191-200

Authors: Bernier J, Russi EG, Homey B, Merlano MC, Mesía R, Peyrade F, Budach W

Abstract
BACKGROUND: Radiation dermatitis developing in patients receiving cetuximab concomitantly with radiotherapy for locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) is now recognized to have different pathophysiological and clinical characteristics to the radiation dermatitis associated with radiotherapy or concomitant chemotherapy and radiotherapy. Current grading tools were not designed to grade this type of radiation dermatitis; their use may lead to misclassification of reactions and inappropriate management strategies, potentially compromising cancer treatment.
PATIENTS AND METHODS: An advisory board of seven leading European specialists (three medical oncologists, three radiation oncologists and a dermatologist) with extensive experience of the use of cetuximab plus radiotherapy produced consensus guidelines for the grading and management of radiation dermatitis in patients receiving cetuximab plus radiotherapy.
RESULTS: Modifications to the current, commonly used National Cancer Institute-Common Terminology Criteria for Adverse Events version 4.3 for grading radiation dermatitis were proposed. Updated management guidelines, building on previously published guidelines from 2008, were also proposed.
CONCLUSIONS: The proposed revisions to the grading system and updated management guidelines described here represent important developments toward the more appropriate grading and effective management of radiation dermatitis in patients receiving cetuximab plus radiotherapy for LA SCCHN.

PMID: 21606209 [PubMed - in process]

Prospective comparison of three guideline development methods for treatment of actinic keratosis.

BMJ Qual Saf. 2011 Oct;20(10):832-41

Authors: Borgonjen RJ, van Everdingen JJ, Bik CM, Tuut MK, Spuls PI, van de Kerkhof PC

Abstract
OBJECTIVE: To compare three methods of guideline development, to see whether using alternative evidence-based methods resulted in variation of recommendations for treating actinic keratosis.
METHODS: Method 1 followed a standard multiple session evidence-based approach with a working group. In method 2 recommendations were formulated by a working group during a 2-day conference. Method 3 used one epidemiologist to summarise the evidence and one dermatologist to make clinical recommendations afterwards. Graded recommendations and levels of evidence were compared per therapy across three draft guidelines. The primary outcome was the extent of accordance or discordance. Secondary outcomes were total costs and time period necessary to make a draft guideline.
RESULTS: Therapeutic recommendations and levels of evidence differed in some occasions. However, intraclass correlations between levels of evidence were significant (method 1 vs 2: p = 0.003; method 1 vs 3: p < 0.001). Regarding recommendation variation method 1 and method 2 correlated significant at 0.755 (p = 0.001). Method 1 versus 3 and method 2 versus 3 also showed significant, but lower, correlation coefficients (respectively, 0.493 (p = 0.026) and 0.673 (p = 0.007)). Method 3 was the cheapest and quickest (24,770 euro and 4 months) and method 1 was the most expensive and slowest method (€48,100 euro and 14 months).

CONCLUSIONS: The value of a guideline using alternative evidence-based methods seems to at least equal that of a guideline composed in multiple sessions, that is, for topics with a monodisciplinary character and a relatively small number of conducted trials. In addition, the presented alternatives were more time- and cost-efficient.

PMID: 21617167 [PubMed - in process]

Use of sleep care guidelines in a surgical intensive care unit reduces noise levels and improves patient-reported sleep quality.

Evid Based Nurs. 2011 Oct;14(4):99-100

Authors: Koch S, Noble H

PMID: 21673096 [PubMed - in process]

Patient and hospital characteristics associated with variation in guideline adherence in intrauterine insemination care.

Int J Qual Health Care. 2011 Oct;23(5):574-82

Authors: Hermens RP, Haagen EC, Nelen WL, Tepe EM, Akkermans R, Kremer JA, Grol RP

Abstract
OBJECTIVE: To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care.
DESIGN: Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists.
SETTING AND PARTICIPANTS: Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals.
MAIN OUTCOME MEASURES: Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care.
RESULTS: A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics ‘diagnosis’ and ‘female age’. Only adherence to the guideline recommendation regarding ‘screening for tubal occlusion’ was associated with hospital characteristics (‘hospital size’ and ‘IVF licence’). Large explained variances up to 39% were found for the different models.
CONCLUSIONS: A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics ‘diagnosis’ and ‘female age’. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.

PMID: 21676961 [PubMed - in process]