International Guidelines (international + guideline)

Distribution by Scientific Domains
Distribution within Medical Sciences

Selected Abstracts

Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes

W. A. Cutchie
Abstract Objective To compare international guidelines for the care of women with diabetes and pregnancy with reported current practice among New Zealand tertiary centres. Research design and methods A literature review of national and international guidelines for the care of women with diabetes in pregnancy was undertaken. Guideline activities were placed within nine facets of care, from preconception advice, through pregnancy from screening to follow-up. New Zealand tertiary centres guidelines were obtained and placed in the same framework. Results International guideline consensus was inconsistent across most facets of care. Those for the detection and diagnosis of gestational diabetes mellitus (GDM) were particularly discordant internationally, although intranational agreement has occurred. Conclusions International guidelines for the care of women with diabetes in pregnancy remain fragmented. The development of one set of guidelines based on the consensus of international best practice could overcome many of the misconceptions associated with diabetes in pregnancy. [source]

Effect of the preliminary hydration on gastric emptying time for water in healthy volunteers

Background: International guidelines allow healthy patients to drink clear liquid up to 2 h before general anesthesia. Recently, MRI measurements have been used for tracking gastric volume in humans. Hence, we used MRI to examine the gastric emptying rate of water in healthy volunteers with or without prior water loading. Methods: Fifteen healthy volunteers were enrolled. The participants had MRI examinations on separate days under two different protocols: The preliminary hydration protocol (group H) and the water restriction protocol (group R). After the intake of water, MR imaging was performed every 10 min for 60 min. The gastric content was outlined as area of interest (AOI), and the AOI area of each slice was summated to calculate the volume of gastric contents. Results: The 50% reduction time of gastric volume in group R and group H was 18±9 and 16±8 min (mean±SD), respectively. There were no significant changes between the two groups. Conclusion: The gastric emptying time for water evaluated with MRI was not affected by preliminary hydration, which shows the safety of repeated oral hydrations in the pre-operative period. [source]

Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome

Summary Background, Recurrent, watery diarrhoea affects one-third of patients diagnosed with irritable bowel syndrome (,IBS-D'). Idiopathic bile acid malabsorption (,I-BAM') may be the cause. Aim, To determine the prevalence of I-BAM in patients suffering from IBS-D. Methods, A systematic search was performed of publications reporting patients presenting with IBS-D type symptoms, who were subsequently confirmed as having I-BAM by SeHCAT scanning. Results, Eighteen relevant studies, 15 prospective, comprising 1223 patients were identified. Five studies (429 patients) indicated that 10% (CI: 7,13) patients had severe bile acid malabsorption (SeHCAT 7 day retention <5% of baseline value). 17 studies (1073 patients) indicated that 32% (CI: 29,35) patients had moderate bile acid malabsorption (SeHCAT <10%). 7 studies (618 patients) indicated that 26% (CI: 23,30) patients had mild (SeHCAT <15%) bile acid malabsorption. Pooled data from 15 studies showed a dose-response relationship according to severity of malabsorption to treatment with a bile acid binder: response to colestyramine occurred in 96% of patients with <5% retention, 80% at <10% retention and 70% at <15% retention. Conclusions, Idiopathic adult-onset bile acid malabsorption is not rare. International guidelines for the management of irritable bowel syndrome need to be revised so that clinicians become more aware of this possibility. [source]

Regular vs prn nebulized treatment in wheeze preschool children

ALLERGY, Issue 10 2009
A. Papi
Background:, International guidelines recommend regular treatment with inhaled glucocorticoids for children with frequent wheezing; however, prn inhaled bronchodilator alone or in combination with glucocorticoid is also often used in practice. We aimed to evaluate whether regular nebulized glucocorticoid plus a prn bronchodilator or a prn nebulized bronchodilator/glucocorticoid combination is more effective than prn bronchodilator alone in preschool children with frequent wheeze. Methods:, Double-blind, double-dummy, randomized, parallel-group trial. After a 2-week run-in period, 276 symptomatic children with frequent wheeze, aged 1,4 years, were randomly assigned to three groups for a 3-month nebulized treatment: (1) 400 ,g beclomethasone bid plus 2500 ,g salbutamol prn; (2) placebo bid plus 800 ,g beclomethasone/1600 ,g salbutamol combination prn; (3) placebo bid plus 2500 ,g salbutamol prn. The percentage of symptom-free days was the primary outcome measure. Secondary outcomes included symptom scores, use of relief medication and exacerbation frequency. Results:, As compared with prn salbutamol (61.0 ± 24.83 [SD]), the percentage of symptom-free days was higher with regular beclomethasone (69.6%, SD 20.89; P = 0.034) but not with prn combination (64.9%, SD 24.74). Results were no different in children with or without risk factors for developing persistent asthma. The effect of prn combination was no different from that of regular beclomethasone on the primary and on several important secondary outcomes. Conclusions:, Regular inhaled glucocorticoid is the most effective treatment for frequent wheezing in preschool children. However, prn bronchodilator/glucocorticoid combination might be an alternative option, but it requires further study. [source]

Thromboprophylaxis practice patterns in hip fracture surgery patients: experience in Perth, Western Australia

Susan Wan
Background: International guidelines recommend that all patients undergoing hip fracture surgery receive specific thromboprophylaxis. The purpose of the present study was to examine current thromboprophylaxis practice patterns in patients undergoing hip fracture surgery at Royal Perth Hospital. Methods: A total of 129 consecutive patients admitted to Royal Perth Hospital between 4 February and 21 July 2002 for surgical repair of a fractured neck of femur, was studied. The primary outcome was the frequency, type, and duration of thromboprophylaxis use during hospitalization. Results: Mean patient age was 79.4 ± 13.4 years and 69.8% (90/129) were female. Seventy-four patients (57.8%; 95% confidence interval (CI): 48.8,66.8%) received specific thromboprophylaxis during hospitalization, including 50 patients (39.1%; 95%CI: 30.6,48.1%) who received pharmacological prophylaxis only, three (2.3%; 95%CI: 0.5,6.7%) who received mechanical prophylaxis only, and 21 (16.4%; 95%CI: 10.5,24.0%) who received both mechanical and pharmacological prophylaxis. Of those receiving pharmacological prophylaxis, 35 (49.3%; 95%CI: 37.2,61.4%) received low-molecular-weight heparin, 26 (36.6%; 95%CI: 25.5,48.9%) received low-dose unfractionated heparin, eight (11.3%; 95%CI: 5.0,21.0%) received warfarin, 35 (49.3%; 95%CI: 37.2,61.8%) received aspirin or clopidogrel, and 27 (38.0%; 95% CI: 26.8,50.3%) received combined anticoagulant and antiplatelet prophylaxis. The median duration of mechanical prophylaxis was 8 days (range: 6,12 days) and that of pharmacological prophylaxis was 12 days (range: 6,26 days). When the 32 patients already taking aspirin or warfarin at the time of admission were excluded, only 45 (46.9%; 95%CI: 36.6,57.3%) of the remaining 96 patients received specific thromboprophylaxis. Conclusion: Specific thromboprophylaxis remains under-utilized in patients undergoing surgery for hip fracture at Royal Perth Hospital. These data should prompt the implementation of effective strategies to improve thromboprophylaxis practice patterns in high-risk orthopaedic patients. [source]

A rapid test for detection of mite allergens in homes

A. Tsay
Summary Background International guidelines recommend allergen avoidance for asthma management, but do not include making assessments of allergen exposure. Mite allergen exposure cannot be assumed, especially in geographical regions where climatic conditions vary. Objective To develop a rapid test that would enable consumers to detect mite allergen in the home. Methods A lateral flow test using gold labelled antibody for mite group 2 allergen was developed as part of a detection kit incorporating the MITEST dust sampling device. Dust samples were assayed by ELISA for group 1 and group 2 allergens and by using the rapid test. The tests were compared as indices of mite allergen exposure. Results There was a good correlation between group 1 and group 2 levels by ELISA (n = 349, r = 0.60, P < 0.001). In a multi-centre study of 65 homes (263 dust samples) in five countries, there was a strong correlation between ELISA and the rapid test. Most samples with high scores in the test (43/48, 90%) contained > 1 µg/m2 group 2 allergen, whereas most low samples contained < 1 µg/m2 (50/64, 78%). Differences between mean group 2 levels of samples that scored low (0.28 µg/m2), medium (1.68 µg/m2) or high (3.18 µg/m2) on the test were highly significant (P 0.007 to < 0.001). Conclusions A simple rapid test has been developed that detects mite allergen in the home within 10 min. The mite screening test should educate consumers about allergen exposure and encourage compliance with allergen-avoidance procedures. This technology has applications for the detection of other common environmental allergens. [source]

,What should I do with a 60-year old man with a slightly low serum total testosterone concentration and normal levels of serum gonadotrophins'?

T. Hugh Jones
Summary The fundamental question in assessing an older man with a slightly low total testosterone and normal gonadotrophin levels is to determine whether or not he has clinical hypogonadism. Hypogonadism is defined as a clinical syndrome complex, which comprises both symptoms as well as biochemical testosterone deficiency. As symptoms are nonspecific and there are no clear cut-off values for testosterone levels this invariably leads to a clinical dilemma. International guidelines have been published which provide recommendations to aid the clinician in making a diagnosis. Late-onset hypogonadism, the preferred terminology for age-related hypogonadism, can only be made once other causes have been excluded. Evidence shows that low testosterone levels are associated with several common male conditions including erectile dysfunction, osteoporosis and diabetes. Short-term studies have shown benefits of testosterone replacement therapy (TRT) on body composition, bone metabolism, insulin resistance, sexual function and quality of life. Recommendations give clear advice on safety monitoring, specifically in relation to prostate health. If a diagnosis of hypogonadism is made with borderline testosterone levels then a 3-month trial of TRT can be considered. The diagnosis of hypogonadism associated with borderline testosterone levels and the decision to treat should only be made by an experienced clinician. [source]

Shoe contact dermatitis from dimethyl fumarate: clinical manifestations, patch test results, chemical analysis, and source of exposure

Ana Giménez-Arnau
Background: The methyl ester form of fumaric acid named dimethyl fumarate (DMF) is an effective mould-growth inhibitor. Its irritating and sensitizing properties were demonstrated in animal models. Recently, DMF has been identified as responsible for furniture contact dermatitis in Europe. Objective: To describe the clinical manifestations, patch test results, shoe chemical analysis, and source of exposure to DMF-induced shoe contact dermatitis. Patients, Materials, and Methods: Patients with suspected shoe contact dermatitis were studied in compliance with the Declaration of Helsinki. Patch test results obtained with their own shoe and the European baseline series, acrylates and fumaric acid esters (FAE), were recorded according to international guidelines. The content of DMF in shoes was analysed with gas chromatography and mass spectrometry. Results: Acute, immediate irritant contact dermatitis and non-immunological contact urticaria were observed in eight adults and two children, respectively. All the adult patients studied developed a delayed sensitization demonstrated by a positive patch testing to DMF , 0.1% in pet. Cross-reactivity with other FAEs and acrylates was observed. At least 12 different shoe brands were investigated. The chemical analysis from the available shoes showed the presence of DMF. Conclusion: DMF in shoes was responsible for severe contact dermatitis. Global preventive measures for avoiding contact with DMF are necessary. [source]


ABSTRACT This article discusses what ,global bioethics' means today and what features make bioethical research ,global'. The article provides a historical view of the development of the field of ,bioethics', from medical ethics to the wider study of bioethics in a global context. It critically examines the particular problems that ,global bioethics' research faces across cultural and political borders and suggests some solutions on how to move towards a more balanced and culturally less biased dialogue in the issues of bioethics. The main thesis is that we need to bring global and local aspects closer together, when looking for international guidelines, by paying more attention to particular cultures and local economic and social circumstances in reaching a shared understanding of the main values and principles of bioethics, and in building ,biodemocracy'. [source]


ABSTRACT Relatively little has been written about the ethics of conducting early phase clinical trials involving subjects from the developing world. Below, I analyze ethical issues surrounding one of gene transfer's most widely praised studies conducted to date: in this study, Italian investigators recruited two subjects from the developing world who were ineligible for standard of care because of economic considerations. Though the study seems to have rendered a cure in these two subjects, it does not appear to have complied with various international guidelines that require that clinical trials conducted in the developing world be responsive to their populations' health needs. Nevertheless, policies devised to address large scale, late stage trials, such as the AZT short-course placebo trials, map somewhat awkwardly to early phase studies. I argue that interest in conducting translational research in the developing world, particularly in the context of hemophilia trials, should motivate more rigorous ethical thinking around clinical trials involving economically disadvantaged populations. [source]


ABSTRACT The aim of this paper is to show that any process of benefit sharing that does not guarantee the representation and participation of women in the decision-making process, as well as in the distribution of benefits, contravenes a central demand of social justice. It is argued that women, particularly in developing countries, can be excluded from benefits derived from genetic research because of existing social structures that promote and maintain discrimination. The paper describes how the structural problem of gender-based inequity can impact on benefit sharing processes. At the same time, examples are given of poor women's ability to organise themselves and to achieve social benefits for entire communities. Relevant international guidelines (e.g. the Convention on Biodiversity) recognise the importance of women's contributions to the protection of biodiversity and thereby, implicitly, their right to a share of the benefits, but no mechanism is outlined on how to bring this about. The authors make a clear recommendation to ensure women's participation in benefit sharing negotiations by demanding seats at the negotiation table. [source]


ABSTRACT This module will introduce you to the ethical concepts underlying applied ethical decision-making in the area of research involving human participants. We will also learn what the issues are that people involved in research on research ethics are concerned with. Ethics without an understanding of historical and legal context makes arguably little sense. It is for this reason that this module will begin with a brief history of research ethics and ends with a brief overview of the relevant national and international guidelines pertaining to ethical issues in research involving human participants. [source]

Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes

W. A. Cutchie
Abstract Objective To compare international guidelines for the care of women with diabetes and pregnancy with reported current practice among New Zealand tertiary centres. Research design and methods A literature review of national and international guidelines for the care of women with diabetes in pregnancy was undertaken. Guideline activities were placed within nine facets of care, from preconception advice, through pregnancy from screening to follow-up. New Zealand tertiary centres guidelines were obtained and placed in the same framework. Results International guideline consensus was inconsistent across most facets of care. Those for the detection and diagnosis of gestational diabetes mellitus (GDM) were particularly discordant internationally, although intranational agreement has occurred. Conclusions International guidelines for the care of women with diabetes in pregnancy remain fragmented. The development of one set of guidelines based on the consensus of international best practice could overcome many of the misconceptions associated with diabetes in pregnancy. [source]

International survey on esophageal cancer: part II staging and neoadjuvant therapy

J. Boone
SUMMARY The outcome of esophagectomy could be improved by optimal diagnostic strategies leading to adequate preoperative patient selection. Neoadjuvant therapy could improve outcome by increasing the number of radical resections and by controlling metastatic disease. The purposes of this study were to gain insight into the current worldwide practice of staging modalities and neoadjuvant therapy in esophageal cancer, and to detect intercontinental differences. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology , Group d'Etude Européen des Maladies de l'Oesophage, and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding staging modalities, neoadjuvant therapy, and response evaluation applied in esophageal cancer patients. Of 567 invited surgeons, 269 participated resulting in a response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%) represented 41 countries across the six continents. Esophagogastroscopy with biopsy and computed tomography (CT) scanning were routinely performed by 98% of responders for diagnosing and staging esophageal cancer, while endoscopic ultrasound (EUS) and barium esophagography were routinely applied by 58% and 51%, respectively. Neoadjuvant therapy is routinely administered by 33% and occasionally by 63% of responders. Of the responders that administer identical neoadjuvant regimens to esophageal adenocarcinoma (AC) and squamous cell carcinoma, 54% favor chemoradiotherapy. For AC, chemotherapy is preferred by 31% of the responders that administer neoadjuvant therapy, whereas for squamous cell carcinoma, the majority of responders (38%) prefer chemoradiotherapy. Response to neoadjuvant therapy is predominantly assessed by CT scanning of the chest and abdomen (86%). Barium esophagography, EUS, and combined CT/PET scan are requested for response monitoring in equal frequency (25%). Substantial differences in applied staging modalities and neoadjuvant regimens were detected between surgeons from different continents. In conclusion, currently the most commonly applied diagnostic modalities for staging and restaging esophageal cancer are CT scanning of the chest and abdomen, gastroscopy, barium esophagography and EUS. Neoadjuvant therapy is routinely applied by one third of the responders. Intercontinental differences have been detected in the diagnostic modalities applied in esophageal cancer staging and in the administration of neoadjuvant therapy. The results of this survey provide baseline data for future research and for the development of international guidelines. [source]

Sustained virologic response prevents the development of esophageal varices in compensated, Child-Pugh class A hepatitis C virus,induced cirrhosis.

HEPATOLOGY, Issue 6 2010
A 12-year prospective follow-up study
The incidence of de novo development of esophageal varices (EV) in patients with compensated liver cirrhosis has been determined by few studies in the short term and never in the long term. The aims of the present study were to determine the incidence and the risk factors associated with the development of EV and to assess whether antiviral treatment and achievement of sustained virologic response (SVR) may prevent de novo EV development in patients with HCV-induced cirrhosis. We studied 218 patients with compensated EV-free, HCV-induced cirrhosis consecutively enrolled between 1989 and 1992 at three referral centers in Milan, Italy. Endoscopic surveillance was performed at 3-year intervals according to international guidelines. SVR was defined as undetectable serum HCV-RNA 24 weeks after treatment discontinuation. During a median follow-up of 11.4 years, 149/218 (68%) patients received antiviral treatment and 34 (22.8%) achieved SVR. None of the SVR patients developed EV compared with 22 (31.8%) of the 69 untreated subjects (P < 0.0001) and 45 (39.1%) of the 115 non-SVR patients (P < 0.0001). On multivariate analysis, HCV genotype 1b (hazard ratio [HR] 2.40; 95% confidence interval [CI] 1.17-4.90) and baseline model for end-stage liver disease (MELD) score (HR 1.20; 95% CI 1.07-1.35 for 1 point increase) were independent predictors of EV. Conclusion: In the long term, the achievement of SVR prevents the development of EV in patients with compensated HCV-induced cirrhosis. Therefore, in these patients, endoscopic surveillance can be safely delayed or avoided. Genotype 1b infection and MELD score identify the subset of patients at higher risk of EV development who need tailored endoscopic surveillance. Hepatology 2010 [source]

5-Aminosalicylic acid (mesalazine) use in Crohn's disease: A survey of the opinions and practice of Australian gastroenterologists

Richard B. Gearry MD
Abstract Background: The use of 5-aminosalicylate (5-ASA) drugs in Crohn's disease (CD) is controversial, with their continuing apparent widespread use despite high-level evidence indicating marginal benefit at best and international guidelines recommending limited indications. Methods: In order to understand how clinicians translate the evidence base into clinical practice, we surveyed a cross-section of Australian gastroenterologists to determine opinions and prescribing patterns of 5-ASA drugs in CD. Results: In all, 42% of 285 gastroenterologists who were sent a questionnaire by e-mail responded. Five (4%) never use 5-ASA drugs in CD. The drugs are most commonly prescribed for patients with colonic (96%) or ileocolonic (92%) disease location, inflammatory disease behavior (80%), and mild disease activity (97%). The majority (64%) use a dose of 1,3 g/day, but only 6% use over 4.5 g/day. Less than one-half use 5-ASA drugs as maintenance following surgical resection, but most use it for inducing remission alone (70%) or in combination with other drugs (90%), and continue its use for maintenance. Side effects are thought to be infrequent (62%) or rare (20%) and few common side effects are believed to be serious. Respondents estimated that over 90% of patients were nonadherent to prescribed 5-ASA regimens at least 50% of the time. While 84% believed that 5-ASA drugs were effective in CD, only 58% believed that they were cost-effective. Conclusions: In Australia 5-ASA drugs are extensively prescribed for CD at relatively low doses without expectation of patient adherence. Current evidence and guidelines has had little apparent impact on clinical practice. The cost implications are considerable. (Inflamm Bowel Dis 2007) [source]

An assessment of endocrine disruption in mollusks and the potential for developing internationally standardized mollusk life cycle test guidelines,

Peter Matthiessen
Abstract This paper summarizes what is known about the endocrine systems of mollusks and how they can be disrupted by exogenous substances. It then examines the various possibilities for using mollusk-based toxicity tests to detect and assess the environmental risks of endocrine-disrupting chemicals (EDCs). It is concluded that there are no internationally standardized tests with mollusks available at present that are suitable for assessing the risks of long-term exposure to EDCs but that several published methods show potential. At the present state of knowledge, the most promising mollusk species for use in partial life cycle testing is probably the fresh- and brackish-water mesogastropod, Potamopyrgus antipodarum, which is known to be responsive to both direct and indirect androgens and to estrogens (and their mimics). Less experience of full life cycle testing exists with mollusks, but the freshwater pulmonate gastropod Lymnaea stagnalis at present offers the best possibility for a practical procedure. In both cases, there is a need for substantial test optimization and validation before these procedures could form the basis of international guidelines. [source]

Audit of community-based anticoagulant monitoring in patients with thromboembolic disease: is frequent testing necessary?

L. Young
Abstract Oral anticoagulant monitoring is managed by general practitioners in Auckland. An audit of this service in 452 patients demonstrated that anticoagulant control was in line with recommended international guidelines, with 58.3% of international normalized ratio (INR) measurements in the therapeutic range. However, the frequency of testing was high, with the majority of patients (68%), including those on long-term treatment, having INR measurements at weekly intervals. We question the need for such frequent INR testing. (Intern Med J 2004; 34: 639,641) [source]

Creating consumer satisfaction in maternity care: the neglected needs of migrants, asylum seekers and refugees

Birgit Jentsch
Abstract An estimated 190 million people are now living outside their countries of birth or citizenship, and the rate of this migration is expected to remain high. The resulting growing cultural and ethnic diversity in societies adds specific challenges to the requirement of delivering public services such as health care to consumers. Globally, about half of the migrant population are women. Migrants' outcomes of pregnancy are known to be poor, showing significant disparities when compared with those of native populations. Although these disparities have been noted, knowledge is limited regarding the availability and accessibility of healthcare services, as well as the acceptability of maternity care for women with experiences of free and forced migration. Healthcare research in general, and maternity care research specifically, have often neglected this population. This paper examines the existing international guidelines intended to address inequities in health outcomes, policies which have been introduced at national levels, and the widely used concepts of ,patient-centred' and ,woman-centred' health services. The ideals implicit in those guidelines and concepts are contrasted with the available evidence of many overseas nationals' experiences with healthcare provisions in general, and maternity care in particular. This is followed by reflections on deficiencies in current studies and on those methodological problems which make research on maternity care for migrant women particularly challenging. The conclusion considers the appropriateness and relevance of guidelines currently promoting equity in maternity care and suggests a future agenda for priority research. [source]

Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2 , a three-arm randomised-controlled clinical trial

T. Reiff
Moderate to severe (,70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4,7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017. [source]

Risk-Based Classification of Hypertension and the Role of Combination Therapy

Matthew R. Weir MD
The recognition of a continuous relationship between elevated blood pressure (BP) and cardiovascular risk has influenced national and international guidelines for the classification, prevention, and management of hypertension. The most recent report (2003) of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure uses BP thresholds to define categories of normal, prehypertension, and hypertension. A new definition proposed by the Hypertension Writing Group in 2005 offers an approach to diagnosis and management based on global or total risk. Thus, even in the absence of sustained elevations in BP, patients may have a moderate to high risk of vascular events due to the presence of additional cardiovascular risk factors, disease markers, and target organ damage. The 2007 European guidelines continue to classify hypertension based on cutoffs while also placing emphasis on multivariate formulations for cardiovascular risk assessment and goals of therapy. All 3 sets of guidelines acknowledge the necessity of using ,2 antihypertensive agents to attain BP goals in many patients. [source]

Review of non-invasive ventilation in the emergency department: clinical considerations and management priorities

Louise Rose
Aims and objectives., We aimed to synthesise evidence from published literature on non-invasive ventilation to inform nurses involved in the clinical management of non-invasive ventilation in the emergency department. Background., Non-invasive ventilation is a form of ventilatory support that does not require endotracheal intubation and is used in the early management of acute respiratory failure in emergency departments. Safe delivery of this intervention requires a skilled team, educated and experienced in appropriate patient selection, available devices and monitoring priorities. Design., Systematic review. Method., A multi-database search was performed to identify works published in the English language between 1998,2008. Search terms included: non-invasive ventilation, continuous positive airway pressure and emergency department. Inclusion and exclusion criteria for the review were identified and systematically applied. Results., Terminology used to describe aspects of non-invasive ventilation is ambiguous. Two international guidelines inform the delivery of this intervention, however, much research has been undertaken since these publications. Strong evidence exists for non-invasive ventilation for patients with acute exacerbation of congestive heart failure and chronic obstructive pulmonary disease. Non-invasive ventilation may be delivered with various interfaces and modes; little evidence is available for the superiority of individual interfaces or modes. Conclusions., Early use of non-invasive ventilation for the management of acute respiratory failure may reduce mortality and morbidity. Though international guidelines exist, specific recommendations to guide the selection of modes, settings or interfaces for various aetiologies are lacking due to the absence of empirical evidence. Relevance to clinical practice., Monitoring of non-invasive ventilation should focus on assessment of response to treatment, respiratory and haemodynamic stability, patient comfort and presence of air leaks. Complications are related to mask-fit and high air flows; serious complications are few and occur infrequently. The use of non-invasive ventilation has resource implications that must be considered to provide effective and safe management in the emergency department. [source]

Differences in prevalence of pressure ulcers between the Netherlands and Germany , associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes

Antje Tannen MA
Aim., This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background., Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the population's vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. Method., In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. Results., In-patients of 29 German (n = 2531) and 71 Dutch (n = 10 098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10 237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8·1 times higher for Dutch nursing home residents than for German residents. Conclusion., Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. Relevance to clinical practice., The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines. [source]

Inducements for medical and health research: issues for the profession of nursing

FRCNA, Linda Shields PhD
Aims and objectives., Inducements, incentives, reimbursements and payment to subjects for participation in research projects raise many practical, professional and philosophical issues for nurses. Nurses are enjoined, either formally as research co-participants or informally as patients' professional carers, in any research which involves their patients. This role inescapably brings significant ethical obligations, which include those of bioethical audit. Background., A review of current international guidelines on reimbursement recommendations indicates that researchers select one of several paradigms which range from the ,commercial market model' of supply and demand to that of pure un-reimbursed altruism. In this latter, volunteers not only give their bodies and emotional commitment, but also sacrifice their time and convenience. Inducement is defined as the provision of resources or rewards which exceed the ,resource neutral' compensation for legitimate expense. If potential volunteers are truly free to make an informed choice to participate in research, no ethical compromise exists if inducements are offered; but by so doing both the research team and the volunteer patients have shifted the ethos of their research from caritas and altruism to one of a simple commercial relationship. Conclusions., Inducements are inappropriate when offered to those who are ,ethically captive' in the sense that autonomy of choice may be compromised. Relevance to clinical practice., In contemporary nursing practice, research involvement is both frequent and desirable. A perspective of current debate about inducements for volunteering, including legal and ethical issues, empowers nurses to protect the patients or clients in their care. [source]

Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines

Cathy Lodewijckx RN MSc PhD Cand
Abstract Rationale, Chronic obstructive pulmonary disease (COPD) exacerbations are a leading cause of hospitalization. Suboptimal inhospital management is expected to lead to more frequent exacerbations and recurrent hospital admission, and is associated with increased mortality. Aims, To explore inhospital management of COPD and to compare the results with recommendations from international guidelines. Methods, A literature search was carried out for relevant articles published 2000,2009 in the databases Medline, Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and Invert. In addition, the reference lists of the selected articles were examined. Main inclusion criteria were as follows: COPD, exacerbation, hospitalization, description of inpatient management, and clinical trials. Assessment and treatment strategies in different studies were analysed and compared with American Thoracic Society-European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease guidelines. Outcomes were analysed. Results, Seven eligible studies were selected. Non-pharmacological treatment was infrequently explored. When compared with international guidelines, diagnostic assessment and therapy were suboptimal, especially non-pharmacological treatment. Respiratory physicians were more likely to perform recommended interventions than non-respiratory physicians. Conclusions, Adherence to international guidelines is low for inhospital management of COPD exacerbations, especially in terms of non-pharmacological treatment. Further investigation is recommended to explore strategies like care pathways that improve performance of recommended interventions. [source]

Pressure ulcer prevention in intensive care patients: guidelines and practice

Eman S. M. Shahin BSc MSc RN PhD
Abstract Background, Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention. Design, The design of this study was a cross-sectional study (point prevalence). Setting, The study setting was intensive care units. The sample consisted of 169 patients , 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards. Results, The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients. Conclusions, The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines. [source]

Current practice compared with the international guidelines: endoscopic surveillance of Barrett's esophagus

Nassira Amamra MPH
Abstract Rationale, aims and objectives, To describe the current practice for the surveillance of patients with Barrett's esophagus, to compare this practice with the national guidelines published by the French Society of Digestive Endoscopy in 1998 and to identify the factors associated with the compliance to guidelines. Method, To determine the attitudes of French hepatogastroenterologists to screening for Barrett's oesophagus, a postal anonymous questionnaire survey was undertaken. It was sent to 246 hepatogastroenterologists in the Rhone-Alpes area. We defined eight criteria allowed to assess the conformity of practices with the guidelines. We created three topics composed of several criterion. The topics analysed were ,Biopsies', ,Surveillance' and the diagnosis of high grade dysplasia. We studied the factors which could be associated with the compliance with the guidelines. Results, The response rate was 81.3%. For 58.0% of the gastroenterologists, endoscopic biopsy sampling were made according to French guidelines (four-quadrant biopsies at 2 cm intervals). Agreement was 78.0% regarding the interval of surveillance for no dysplasia (every 2 or 3 years) and 78.5% regarding the low-grade dysplasia (every 6 or 12 months). For the management of high-grade dysplasia, 28.6% actually confirm the diagnosis by a second anatomopathologist and 42.0% treated by proton pump inhibitor during 2 months. Concerning the biopsies, the young gastroenterologists and gastroenterologists practising in university hospitals had a better adherence to the guidelines (Relative Risk: 2.22, 95% CI 1.25,3.95 and 3.74, 95% CI 1.04,13.47, respectively). The other factors of risk were not statistically significant. Conclusions, The endoscopic follow-up is mostly realized in accordance with the national guidelines. However, there is a wide variability in individual current practice. [source]

Detection and validated quantification of nine herbal phenalkylamines and methcathinone in human blood plasma by LC-MS/MS with electrospray ionization

Jochen Beyer
Abstract The herbal stimulants Ephedra species, Catha edulis (khat), and Lophophora williamsii (peyote) have been abused for a long time. In recent years, the herbal drug market has grown owing to publicity on the Internet. Some ingredients of these plants are also ingredients of cold remedies. The aim of the presented study is to develop a multianalyte procedure for detection and validated quantification of the phenalkylamines ephedrine, pseudoephedrine, norephedrine, norpseudoephedrine, methylephedrine, methylpseudoephedrine, cathinone, mescaline, synephrine (oxedrine), and methcathinone in plasma. After mixed-mode solid-phase extraction of 1 ml of plasma, the analytes were separated using a strong cation exchange separation column and gradient elution. They were detected using a Q-Trap LC-ESI-MS/MS system (MRM mode). Calibration curves were used for quantification using norephedrine- d3, ephedrine- d3, and mescaline- d9 as internal standards. The method was validated according to international guidelines. The assay was selective for the tested compounds. It was linear from 10 to 1000 ng/ml for all analytes. The recoveries were generally higher than 70%. Accuracy ranged from , 0.8 to 20.0%, repeatability from 2.5 to 12.3%, and intermediate precision from 4.6 to 20.0%. The lower limit of quantification was 10 ng/ml for all analytes. No instability was observed after repeated freezing and thawing or in processed samples. The applicability of the assay was tested by analysis of authentic plasma samples after ingestion of different cold medications containing ephedrine or pseudoephedrine, and after ingestion of an aqueous extract of Herba Ephedra. After ingestion of the cold medications, only the corresponding single alkaloids were detected in human plasma, whereas after ingestion of the herb extract, all six ephedrines contained in the plant were detected. The presented LC-MS/MS assay was found applicable for sensitive detection and accurate and precise quantification of all studied analytes in plasma. Copyright © 2006 John Wiley & Sons, Ltd. [source]

Predictive genetic testing in young people: When is it appropriate?

RE Duncan
Abstract: Predictive genetic testing is currently offered to adults for a range of conditions, even when there is no possibility of prophylaxis or treatment. However, similar testing in children and adolescents is advised against in international guidelines. Despite this, several authors have argued against the existing guidelines. Given the lack of empirical evidence, it is important that clinicians are aware not only of the guidelines, but also of the arguments in favour of such testing. [source]

Association Between Quality of Cheap and Unrecorded Alcohol Products and Public Health Consequences in Poland

ALCOHOLISM, Issue 10 2009
Dirk W. Lachenmeier
Background:, The research aimed to study the quality of cheap alcohol products in Poland. These included unrecorded alcohols (i.e., home-produced or illegally imported), estimated to constitute more than 25% of total consumption and fruit wines. Methods:, A sample of alcohol products (n = 52) was collected from local markets and chemical analyses were conducted. The parameters studied were alcoholic strength, volatiles (methanol, acetaldehyde, and higher alcohols), ethyl carbamate, inorganic elements, and food additives including preservatives, colors, and sweeteners. The compositions of the beverages were then toxicologically evaluated using international standards. Results:, With the exception of 1 fortified wine, the unrecorded alcohols were home-produced fruit-derived spirits (moonshine) and spirits imported from other countries. We did not detect any nonbeverage surrogate alcohol. The unrecorded spirits contained, on average, 45% vol of alcohol. However, some products with considerably higher alcoholic strengths were found (up to 85% vol) with no labeling of the content on the bottles. These products may cause more pronounced detrimental health effects (e.g., liver cirrhosis, injuries, some forms of malignant neoplasms, alcohol use disorders, and cardiovascular disease) than will commercial beverages, especially as the consumer may be unaware of the alcohol content consumed. Fruit wines containing between 9.5 and 12.2% vol alcohol showed problems in terms of their additive content and their labeling (e.g., sulfites, sorbic acid, saccharin, and artificial colors) and should be subjected to stricter control. Regarding the other components investigated, the suspected human carcinogens, acetaldehyde and ethyl carbamate, were found at levels relevant to public health concerns. While acetaldehyde is a typical constituent of fermented beverages, ethyl carbamate was found only in home-produced unrecorded alcohols derived from stone fruits with levels significantly above international guidelines. Conclusions:, The contamination of unrecorded alcohols with ethyl carbamate should be analyzed in a larger sample that also should include legal alcoholic beverages. Furthermore, the impacts of unrecorded alcohol on the health of people with lower socioeconomic status should be studied in detail. Overall, given the extent of the alcohol-attributable disease burden in Poland, the highest priority should be given to the problem of ethanol and its very high content in unrecorded alcohol products. [source]