National Guidelines (national + guideline)

Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of National Guidelines

  • published national guideline

  • Selected Abstracts

    Working in partnership , developing a young people's service in a rural environment

    M. Mitchell
    Specific objective, The Project reviewed , The Provision of Services for Early Psychosis in Cornwall. It looked at staff feedback, user and carers' views, base line assessment and National Guidelines of Best Practice, and proposed significant changes to meet the needs of young people. Method, The Review was carried out under the auspices of the National Clinical Governance Team and used as its framework the RAID model of change. Results, This resulted in a series of recommendations, which informed new developments. Current initiatives include a Health Promotion Programme, Training Strategies in Primary Care and effective partnerships with young people's services. Conclusions, It proposes significant changes to the correct system of care by working outside the traditional healthcare settings and across the service boundaries of health, education and social care. The rurality of Cornwall provides a considerable challenge for service delivery. This review ensured that ownership rested with users, careers, staff and others who contributed and shaped its future direction. [source]

    Asthma Pharmacotherapy Prescribing in the Ambulatory Population of the United States: Evidence of Nonadherence to National Guidelines and Implications for Elderly People

    Prakash Navaratnam MPH
    OBJECTIVES: To examine the level of physician adherence to the Expert Panel Report 2 (EPR-2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States. DESIGN: Retrospective cross-sectional study using a national survey. SETTING: National Ambulatory Medical Care Survey data of U.S. elderly patients from 1998 through 2004. PARTICIPANTS: The weighted population sample size was 82,020,318 patients. There were 1,540 observations in this study (preweighted sample size) and 96 strata, with 446 population sampling units (PSUs). There were 11,868,340 patients that were elderly, and they accounted for 14.5% of the overall population sampled. MEASUREMENTS: Specific patient demographic variables, physician demographic variables, and information about asthma medications prescribed were extracted from the data set and analyzed. Descriptive statistics for the patient demographic, physician demographic, and asthma pharmacotherapy variables were generated. A series of logistic regression models were created, with the choice of asthma pharmacotherapy agent used as the dependent variable and patient and physician demographic variables as the independent variables. RESULTS: A major finding was that physicians were not adherent to the National Asthma Education and Prevention Program EPR-2 asthma pharmacotherapy guidelines. Another finding was that, although elderly patients (aged ,65) were exposed to more-stable patterns of care, they were less likely to be prescribed controller medications, long-acting bronchodilators (LABAs), combinations of inhaled corticosteroids and LABAs, and short-acting beta agonists than patients aged 35 to 64. CONCLUSION: A more-concerted effort needs to be undertaken to improve physician adherence to the EPR-2 guidelines, especially in prescribing asthma pharmacotherapy to elderly patients. [source]

    Inconsistent Evidence: Analysis of Six National Guidelines for Vaginal Birth After Cesarean Section

    BIRTH, Issue 1 2010
    GradDipClinEpi, Maralyn Foureur BA
    Abstract:, Background:, Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice. Methods:, English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made. Results:, Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent. Conclusions:, VBAC guidelines are characterized by quasi-experimental evidence and consensus-based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. (BIRTH 37:1 March 2010) [source]

    National guidelines for adult autopsy cardiac dissection and diagnosis , are they achievable?

    HISTOPATHOLOGY, Issue 1 2008
    A personal view
    Adult autopsy cardiac pathology has been previously a quiet backwater of ischaemic heart disease and the occasional cardiomyopathy. This has changed to an increasingly tense area, following recent genetic discoveries and some medicolegal cases. All autopsy pathologists should consider their dissection protocols and check that they are able to deliver the increasingly detailed information that clinicians, geneticists and families require. This text has suggestions about the practical realities of cardiac dissection, cardiac histology and the need for other tests alongside illustrations aimed to assist case consideration. [source]

    An Educational Intervention to Improve Antimicrobial Use in a Hospital-Based Long-Term Care Facility

    (See Editorial Comments by Dr. Lona Mody on pp 130, 1302)
    OBJECTIVES: To improve antimicrobial use in patients receiving long-term care (LTC). DESIGN: Prospective, quasi-experimental before,after assessment of the effects of physician education and guideline implementation. SETTING: Public LTC and acute care hospital. PARTICIPANTS: Twenty salaried internists who provided most of the medical care to LTC patients. INTERVENTION: National guidelines, hospital resistance data, and physician feedback were incorporated into a series of four teaching sessions presented over 18 months and into booklets detailing institutional guidelines on the optimal management of common LTC infection syndromes. MEASUREMENTS: One hundred randomly selected LTC patients treated with antimicrobials were reviewed before these interventions were implemented and 100 after, and measures of the quality of care were compared. The effect of the interventions on antimicrobial days and starts were also assessed using interrupted time series analysis. RESULTS: Charted clinical abnormalities met guideline diagnostic criteria (62% vs 38%, P=.006), and initial therapy agreed with guideline recommendations (39% vs 11%, P<.001), more often in the post- than in the preintervention cohort. Mean census-adjusted monthly LTC antimicrobial days fell 29.7%, and antimicrobial starts fell 25.9% during the intervention period; both decreases were sustained during the 2-year postintervention period. CONCLUSION: The teaching and guideline intervention improved the quality and reduced the quantity of antimicrobial use in LTC patients. [source]

    Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

    Background: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. Methods: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. Results: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. Conclusions: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on [source]

    Percutaneous Coronary Intervention, Comorbidities, and Mortality among Emergency Department,Admitted ST-Elevation Myocardial Infarction Patients in Florida

    Background: Risk of mortality following an ST-elevation myocardial infarction (STEMI) can be significantly reduced by prompt percutaneous coronary intervention (PCI). National guidelines specify primary PCI as the preferred recommended treatment for STEMI. In this study, we examined same-day PCI as an independent predictor of in-hospital mortality, after adjustment for comorbidities, other patient factors, and hospital PCI-volume using unselected surveillance data from Florida. Methods: We analyzed hospital discharge data for adults, 18+ years old, with a primary diagnosis of STEMI who were admitted to PCI-capable hospitals through the emergency department during 2001,2005 (n = 43,849). Hierarchical (multilevel) logistic regression models were used for analysis. Results: Overall, 4,143 STEMI patients (9.4%) did not survive to hospital discharge. In late 2005, the in-hospital mortality rates were 1.9% for those who received same-day PCI versus 13.0% for those who did not. After adjustment for multiple patient factors, same-day PCI was a significant predictor of in-hospital survival with a strong protective effect (adjusted OR = 0.35, 95% CI 0.31,0.38 P < 0.0001). Restriction of the analysis to those patients who survived the first day of admission did not appreciably change this result (adjust OR = 0.37, 95% CI 0.33,0.42, P < 0.0001). Hospital PCI-volume did not significantly impact mortality risk. Conclusions: Same-day PCI markedly reduced the risk of in-hospital mortality among STEMI patients after multivariate adjustment. Serious comorbidities and complications, older age, and female gender continued to predict elevated risk of mortality after control for treatment status. Our results provide additional evidence in support of national clinical recommendations and aggressive treatment of STEMI. (J Interven Cardiol 2010;23:205,215) [source]

    Guidelines and the adoption of ,lipid rescue' therapy for local anaesthetic toxicity

    ANAESTHESIA, Issue 2 2009
    J. Picard
    Summary Gathering evidence from animal experiments, an editorial in this journal and published human case reports culminated in the Association of Anaesthetists of Great Britain and Ireland recommending in August 2007 that lipid emulsion be immediately available to all patients given potentially cardiotoxic doses of local anaesthetic drugs. This development offered an opportunity to track the adoption of an innovation by anaesthetists in the UK and to gauge the effects of guidelines. Two surveys, each of 66 NHS hospitals delivering acute care within London and its penumbra, examined the adoption of lipid emulsion therapy. After the publication of the editorial in autumn 2006, the spread of ,lipid rescue' was rapid. The timing of the adoption and the impetus for innovation varied substantially between the sampled hospitals. When the formal guidelines were published, approximately half of the hospitals surveyed did not have lipid rescue. Of those that subsequently adopted it, half attributed their decision to the guidelines. At the end of 2007, there remained a small number of hospitals that had yet to adopt lipid rescue. Lipid rescue's adoption by anaesthetists in the UK offers a rare example of swift uptake of an innovation. National guidelines accelerated the adoption of innovation by some hospitals. [source]

    Epidemiology and prognosis of ovarian metastases in colorectal cancer,

    J. Segelman
    Background: National guidelines for prophylactic oophorectomy in women with colorectal cancer are lacking. The aim of this population-based cohort study was to report on the prevalence, incidence and prognosis of ovarian metastases from colorectal cancer, providing information relevant to the discussion of prophylactic oophorectomy. Methods: All 4566 women with colorectal cancer in Stockholm County during 1995,2006 were included and followed until 2008. Prospectively collected data regarding clinical characteristics, treatment and outcome were obtained from the Regional Quality Registry. Results: The prevalence of ovarian metastases at the time of diagnosis of colorectal cancer was 1·1 per cent (34 of 3172) among women with colonic cancer and 0·6 per cent (8 of 1394) among those with rectal cancer (P = 0·105). After radical resection of stage I,III colorectal cancer, metachronous ovarian metastases were found during follow-up in 1·1 per cent (22 of 1971) with colonic cancer and 0·1 per cent (1 of 881) with rectal cancer (P = 0·006). Survival in patients with ovarian metastases was poor. Conclusion: Ovarian metastases from colorectal cancer are uncommon. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]

    Audit of local performance compared with standards recommended by the national guidelines for aetiologic investigation of permanent childhood hearing impairment

    S. Yoong
    Abstract Background National guidelines for aetiologic investigation of childhood deafness were developed as the Newborn Hearing Screening Program (NHSP) was being implemented in the United Kingdom. This guidance document was expected to be incorporated into the operational procedure of the NHSP. Method This criterion-based audit compared local care set against developed guidelines that can be used to assess the appropriateness of specific investigations, services and outcomes. Data on children diagnosed to have sensorineural deafness from March 2002,2004 were extracted from an established computerized database for analysis. Results Forty-seven children were included; 17 have bilateral severe to profound hearing loss, 25 have bilateral mild to moderate loss and 5 with unilateral loss. A high proportion of Pakistani children were from consanguineous marriages with a family history of deafness. Total 29.8% of children were diagnosed through newborn screening and 70.2% detected through hearing surveillance programmes. For children with bilateral severe to profound deafness, 53.0% accepted, 5.9% declined and 41.2% were not offered imaging of their inner ears. A total of 47.1% accepted and 52.9% declined electrocardiograph (ECG) evaluation. Total 70.6% accepted and 29.4% declined connexin mutations testing. Parental requests were required for those with lesser degree of hearing loss. Total 24% accepted, 28% declined and 48% were not offered connexin testing. None were offered ECG and imaging. Testing for congenital infections was inappropriate for children over 1 year old. Ten subjects accepted and five declined this investigation. In the total group, 63.8% accepted, 17.0% declined and 19.1% were not offered referral to the ophthalmic service. Total 46.8% accepted, 44.7% declined and 8.5% were not offered referral to genetics service. Investigations resulted in two connexin-positive children with moderate loss. Conclusion Our study identified key areas where guidelines were not followed. These were related to lack of funding and parental choice. This sample has a higher connexin ,hit' rate for lesser degree deafness. [source]

    National guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus,what do they tell us?

    H. HumphreysArticle first published online: 30 JUN 200
    Abstract Guidelines to control and prevent methicillin-resistant Staphylococcus aureus (MRSA) infection are available in many countries. Infection control and prevention teams determine local strategies using such national guidelines, but not all guidelines involve a rigorous assessment of the literature to determine the strength of the recommendations. Available guidelines drafted by national agencies or prominent professional organisations in Germany, New Zealand, North America, The Netherlands, Ireland and the UK were reviewed. Significant literature reviews were a component of guidelines from the UK and North America. Recommendations were not graded on the strength of the evidence in guidelines from New Zealand and The Netherlands. The Netherlands, a country with a very low prevalence of MRSA, had the simplest set of guidelines. Few of the recommendations in any of the guidelines achieved the highest grading, i.e., based on well-designed, experimental, clinical or epidemiological studies, even though the logic of the proposed measures is clear. The onset of community-acquired MRSA is reflected in the recent publication of guidelines from North America. New developments, such as rapid testing and mathematical modelling, are of importance in helping to control MRSA in settings of both low and high endemicity. National guidelines are increasingly evidence-based, although good scientific studies concerning some aspects of MRSA control are lacking. However, general principles, e.g., early detection and isolation, are recommended by all guidelines. There is still a role for consensus and the opinion of experts in devising national guidelines. [source]

    Feeding practices of infants through the first year of life in Italy

    ACTA PAEDIATRICA, Issue 4 2004
    M Giovannini
    Aim: To investigate infant feeding practices through the first year of life in Italy, and to identify factors associated with the duration of breastfeeding and early introduction of solid foods. Methods: Structured phone interviews on feeding practices were conducted with 2450 Italian-speaking mothers randomly selected among women who delivered a healthy-term singleton infant in November 1999 in Italy. Interviews were performed 30 d after delivery and when the infants were aged 3, 6, 9 and 12 mo. Type of breastfeeding was classified according to the WHO criteria. Results: Breastfeeding started in 91.1% of infants. At the age of 6 and 12mo, respectively, 46.8% and 11.8% of the infants was still breastfed, 68.4% and 27.7% received formula, and 18.3% and 65.2% were given cow's milk. Solids were introduced at the mean age of 4.3 mo (range 1.6,6.5 mo). Introduction of solids occurred before age 3 and 4 mo in 5.6% and 34.2% of infants, respectively. The first solids introduced were fruit (73.1%) and cereals (63.9%). The main factors (negatively) associated with the duration of breastfeeding were pacifier use (p > 0.0001), early introduction of formula (p > 0.0001), lower mother's age (p > 0.01) and early introduction of solids (p= 0.05). Factors (negatively) associated with the introduction of solids foods before the age of 3 mo were mother not having breastfed (p > 0.01), early introduction of formula (p > 0.01), lower infant bodyweight at the age of 1 mo (p= 0.05) and mother smoking (p= 0.05). Conclusion: The duration of breastfeeding in Italy is still inadequate, as well as compliance with international recommendations for timing of introduction of complementary foods. National guidelines, public messages and educational campaigns should be promoted in Italy. [source]

    Measures of blood loss and red cell transfusion targets for caesarean delivery complicated by placenta praevia

    Rhonda K. BOYLE
    Objective:, The objective of this study was to assess the association between transfusion, per cent drop in haemoglobin (Hb), and estimated blood loss during the delivery and the first postoperative week following caesarean delivery for placenta praevia. Clinical data predictive of an objective laboratory test for risk of haemorrhage and the need for transfusion were investigated. Transfusions outside national Guidelines were noted. Design:, Retrospective observational study of patients with placenta praevia, who were delivered consecutively by caesarean section at Royal Brisbane and Women's Hospital from 1999 to 2005. Setting:, University-affiliated tertiary hospital. All caesareans were performed by one or more consultant obstetricians, gynaecology oncology surgeons and registrar assistants. Results:, Seventy-one (28.9%) of 246 patients with placenta praevia were transfused, with 45 of these receiving three or more red cell units. The antenatal Hb fell by a mean of 20.2% (SD 13.5). The average operative haemorrhage was estimated as 1225 mL (SD 996). No patient or surgical factors were significantly associated with changes in Hb. There was a significant association between per cent fall in antenatal Hb and both transfusion P < 0.001 and estimated loss P = 0.002. After transfusion, the Hb of 19 patients was higher than that recommended by Guidelines. Conclusions:, Whether transfusion is necessary, but not the number of red cell units, can be planned by the effect of haemorrhage on antenatal Hb during delivery by caesarean section complicated by placenta praevia. [source]

    Refill adherence and polypharmacy among patients with type 2 diabetes in general practice

    Rykel van Bruggen PhD
    Abstract Background and Aims Non-adherence is considered a major barrier to better outcomes of diabetes care. A relationship has been established between polypharmacy and patients' adherence. This study aims to investigate the occurrence of polypharmacy and non-adherence in general practice, their mutual relationship and the association between adherence and the intermediate outcomes of diabetes care. Materials and Methods We used the baseline and follow-up data of a randomised controlled trial (RCT) that compared usual care with care in accordance with a locally adapted national guideline. This study took place in the Netherlands and involved 30 general practices and 1283 patients. We obtained a complete medication profile of all participants and calculated the number of prescribed drugs and the adherence indices (AI) for oral blood glucose, blood pressure and cholesterol lowering drugs. Patients with an adherence index <,0.8 were considered non-adherent. Clustering at practice level and case-mix were taken into account. Results Approximately 80% of the participating patients demonstrated an adherence index ,,0.8 for oral blood glucose, blood pressure and cholesterol lowering drugs. In the intervention group, increase of drug prescriptions exceeded that of controls (1.1,±,2.0 vs. 0.6,±,1.5, p,<,0.001, adjusted p,<,0.05). There was evidence of an inverse relationship between the number of drugs that had been prescribed during the last 6 months of the study and patients' adherence to blood pressure lowering medications (adjusted OR 0.84, 95%CI 0.78,0.91). After one year, HbA1c and total cholesterol levels were significantly lower in adherent patients. Conclusion During the intervention the mean number of drug prescriptions increased in both the study groups. This did not result in a lower adherence to blood glucose and cholesterol lowering medications. Given the relationship between the number of medications and patients' adherence to blood pressure lowering drugs, it may be wise to discuss adherence before prescribing multiple drug regimens. Copyright © 2009 John Wiley & Sons, Ltd. [source]

    Are differences in guidelines for the treatment of nicotine dependence and non-nicotine dependence justified?

    ADDICTION, Issue 12 2009
    John R. Hughes
    ABSTRACT Despite the many similarities between nicotine dependence and other drug dependences, national guidelines for their treatment differ in several respects. The recent national guideline for the treatment of nicotine dependence has (i) less emphasis on detailed assessment; (ii) less emphasis on treatment of psychiatric comorbidity; (iii) less acceptance of reduction of use as an initial treatment goal; (iv) greater emphasis on pharmacological interventions; and (v) less emphasis on psychosocial treatment than national guidelines for non-nicotine dependences. These treatment differences may occur because (i) nicotine does not cause behavioral intoxication; (ii) psychiatric comorbidity is less problematic with nicotine dependence; (iii) psychosocial problems are less severe with nicotine dependence; and (iv) available pharmacotherapies for nicotine dependence are safer, more numerous and more easily available. However, it is unclear whether these treatment differences are, in fact, justifiable because of the scarcity of empirical tests. We suggest several possible empirical tests. [source]

    Does prescribing for opiate addiction change after national guidelines?

    ADDICTION, Issue 5 2007
    Methadone, buprenorphine prescribing to opiate addicts by general practitioners, hospital doctors in England
    ABSTRACT Aim To assess changes in opiate prescribing (1995,2005) following a decade of national guidelines to address substandard opiate substitution prescribing for heroin addiction. Design A repeat national survey (1995 and 2005) using random one-in-four samples of all community pharmacies in England, achieving response rates of 75% (1847/2475) in 1995 and 95% (2349/2473) in 2005. Data were obtained on 3732 (1995 data) and 9620 (2005 data) prescriptions dispensed in the preceding month from the 936 and 1463 pharmacies who were currently dispensing. Measurements We have measured impact on practice for seven specific recommended changes. Findings Between 1995 and 2005 the number of substitute opiate prescriptions doubled (×2.03). By 2005, methadone still dominated (down from 97% to 83%), buprenorphine increased (from 1% to 16%) and other opiate medications virtually disappeared. Changes in the direction of national guidelines included: increased daily dose of methadone (from 47.3 mg to 56.3 mg), more frequent dispensing (from 38% to 60% as daily instalments), more supervised consumption (from 0% to 36%) and fewer methadone tablets (from 10.9% to 1.8%). Nevertheless, despite the increased mean daily dose, only 41.0% of prescriptions for methadone were for daily doses in the recommended 60,120 mg dose range. Only one change was not in the direction of the national guidelines,the proportion of prescriptions from GPs fell from 41% to 30%, although this still represented an approximate 50% increase in the extent of GP prescribing. Conclusion Doubling in provision of opiate substitute treatment has occurred, alongside significant improvements in the nature of this treatment. These positive changes have occurred in the direction of six out of seven of the UK national guidelines. [source]

    Prediction of alcohol-related harm from controlled drinking strategies and alcohol consumption trajectories

    ADDICTION, Issue 4 2004
    J. W. Toumbourou
    ABSTRACT Aims To establish predictors of age 21 alcohol-related harm from prior drinking patterns, current levels of alcohol consumption and use of controlled drinking strategies. Participants One thousand, five hundred and ninety-six students recruited from an initial sample of 3300 during their final year of high school in 1993. Design Longitudinal follow-up across five waves of data collection. Setting Post high school in Victoria, Australia. Measurements Self-administered surveys examining a range of health behaviours, including alcohol consumption patterns and related behaviour. Findings Drinking behaviours at age 21 were found to be strongly predicted by drinking trajectories established through the transition from high school. Multivariate regression analysis revealed that alcohol-related harms at age 21 were reduced where current levels of alcohol use fell within limits recommended in Australian national guidelines. After controlling for this effect it was found that the range of strategies employed by participants to control alcohol use maintained a small protective influence. Post-high-school drinking trajectories continued to demonstrate a significant effect after controlling for current behaviours. Findings revealed that over one quarter of males and females drank alcohol, but on a less-than-weekly basis. This pattern of alcohol use demonstrated considerable stability through the post-school transition and was associated with a low level of subsequent harm at age 21. Conclusions Future research should investigate whether encouraging more Australian adolescents to drink alcohol on a less-than-weekly basis may be a practical intervention target for reducing alcohol-related harms. [source]

    Etomidate for Pediatric Sedation Prior to Fracture Reduction

    Richard Dickinson MD
    Abstract. Objective: While etomidate is reported as a procedural sedative in adults, its use in children has not been extensively reported. The authors describe their experience with etomidate for procedural sedation in children with extremity fractures and major joint dislocations. Methods: This was a retrospective descriptive chart review. The setting was a university-based emergency department (ED) that follows national guidelines for procedural sedation. Subjects were children less than 18 years old who received etomidate prior to fracture reduction or major joint dislocations. Standardized data were abstracted from the medical records, including patient demographics, diagnosis, weight, types and doses of sedative and analgesic agents used, number of boluses of etomidate, attempts at reduction, complications encountered, vitals signs before, during, and after the reduction, disposition, and the time from procedure to discharge. Descriptive statistics calculated included means and proportions with 95% confidence intervals. Results: Fifty-three children received etomidate for fracture reduction. Their mean age was 9.7; 41.5% were females. Indications for reduction included forearm fractures (38), ankle fractures (12), upper arm fractures (2), and hip dislocations (1). In most cases (83%) reduction was successful after one attempt only. The mean initial and total doses of etomidate were 0.20 mg/kg (range, 0.1 to 0.4) and 0.24 mg/kg (range, 0.13 to 0.52), respectively. Thirteen patients required a second bolus of etomidate or midazolam. Thirty-four patients (64%) were discharged from the ED after a mean observation of 94 minutes (range, 35 to 255). There were no major adverse events (95% CI = 0% to 5.7%). One patient reported nausea and one required a fluid bolus for hypotension. One patient receiving multiple sedatives and opioid analgesics was admitted for observation due to prolonged sedation. No patient required assisted ventilation or intubation. Conclusions: These results suggest that etomidate is a safe and effective agent for procedural sedation in children requiring fracture and major joint reductions. [source]

    Organic compounds as indicators of air pollution

    INDOOR AIR, Issue 2003
    L. Mølhave
    Abstract The most important indoor air pollutants have already been addressed with individual national guidelines or recommendations. However, an international set of guidelines or recommendations for indoor air quality (IAQ) is needed for these pollutants based on general and uniform rules for setting such standards. A major research need exist on the less adverse pollutants before recommendations or guidelines can be established. In the interim period a precaution principle should lead to an ALARA principle for these secondary causalities. It should be noted that volatile organic compound (VOC) as an IAQ problem still is in the end of a phase of ad hoc solutions, in the middle of a research phase and only in the beginning of a regulatory phase. Any final official regulation in this area will have to be tentative and the final regulation must await further research. Total volatile organic compound (TVOC) is an indicator for the presence of VOC indoors. The TVOC indicator can be used in relation to exposure characterization and source identification but for VOCs only, not as an indictor of other pollutants and their health effects. In risk assessment the TVOC indicator can only be used as a screening tool and only for sensory irritation. [source]

    Duly Authorized Officers' practices under mental health law in New Zealand: Are nurses meeting the requirements of the law?

    Brian McKenna
    ABSTRACT The Mental Health (Compulsory Assessment and Treatment) Act (1992) introduced a number of statutory roles that are undertaken by mental health nurses. One of these roles is that of Duly Authorized Officer (DAO). The DAO is responsible for the procedural requirements necessary to facilitate compulsory assessment. Under Section 9(2)(d), the DAO is required to ensure that the purpose of the assessment and the requirements of the notice of assessment are explained to the person in the presence of a member of their family, a caregiver, or other person concerned with the welfare of the person. Three recent High Court decisions under the Habeas Corpus Act 2001 have challenged existing DAO practices in arranging the presence of a third party. This paper presents research, which focuses on unravelling some of the complexities associated with meeting this procedural requirement. It illustrates these complexities through a discussion of the results of an audit of files and three focus groups with mental health nurses who practise as DAO. The paper concludes that national guidelines for practice need to be developed for DAO to assist mental health nurses in meeting this statutory requirement. [source]

    Aetiology of molar,incisor hypomineralization: a critical review

    Objective., The objective of this study was to assess the strength of evidence for the aetiology of molar,incisor hypomineralization (MIH), often as approximated by demarcated defects. Method., A systematic search of online medical databases was conducted with assessment of titles, abstracts, and finally full articles for selection purposes. The level and quality of evidence were then assessed for each article according to Australian national guidelines. Results., Of 1123 articles identified by the database search, 53 were selected for review. These covered a variety of potential aetiological factors, some of which were grouped together for convenience. The level of evidence provided by the majority of papers was low and most did not specifically investigate MIH. There was moderate evidence that polychlorinated biphenyl/dioxin exposure is involved in the aetiology of MIH; weak evidence for the role of nutrition, birth and neonatal factors, and acute or chronic childhood illness/treatment; and very weak evidence to implicate fluoride or breastfeeding. Conclusion., There is currently insufficient evidence in the literature to establish aetiological factor/s relevant for MIH. Improvements in study design, as well as standardization of diagnostic and examination protocols, would improve the level and strength of evidence. [source]

    Treatment of osteoporosis: facing the challenges in the Asia-Pacific

    Syed Atiqul HAQ
    Abstract The prevalence of osteoporosis and fractures is projected to increase rapidly in the Asia-Pacific region in coming decades. At the societal level, healthcare providers will face the challenges of paucity of information, lack of awareness among physicians, resource constraints, lack of organization, absence of policies of cost reimbursement, insufficient representation of the problem in curricula and lack of effective, inexpensive and convenient therapy. Poverty, illiteracy, lack of awareness and interest in future quality of life, and co-morbidities with seemingly greater importance, will all act as challenges at the level of individual patients. Lack of compliance is a function of lack of awareness and motivation, cost, complexity of administration, side-effects and absence of immediately perceivable benefit. The challenges may be overcome through systematic collection of data, formation or activation of national osteoporosis planning and coordinating groups, development of national guidelines, programs of education of healthcare providers, patients and the general public, adoption of a population-based prevention strategy, cost-effective opportunistic screening using clinical decision rules like the osteoporosis self-assessment tool for Asians, use of the fracture risk assessment tool for therapeutic decision-making, giving due emphasis to the problem in curricula and development of mechanisms for cost reimbursement. The Asia-Pacific League of Associations for Rheumatology may take a lead in stimulating, organizing and coordinating these activities. [source]

    A critical review of aspirin in the secondary prevention of noncardioembolic ischaemic stroke

    Domenico Inzitari
    Both secondary prevention (such as lifestyle modifications, pharmacotherapy or surgery) and an understanding of the influence of risk factors (including the different aetiologic mechanisms of cerebral ischaemia) play a pivotal role in reducing the burden of recurrent stroke. Regarding the types of preventative treatments available, variations exist across all clinical studies, including differences in target populations (including the type of cerebral ischaemia), risk factors, length of follow-up, drop-out rates and outcomes, which makes translating the results of clinical trials to individual patients difficult. However, with such limitations in mind, this critical albeit nonsystematic review, which compared aspirin with other antiplatelets and in combination with other drugs, showed that the benefit from aspirin treatment is consistently shown in ischaemic stroke, while harms are limited. Furthermore, no definite superiority is apparent across different antiplatelet therapies. Dual antiplatelet regimens may expose to a slight but measurable higher risk of haemorrhagic complications, perhaps in selective groups of patients (i.e. those with severe small-vessel disease or in selective racial groups). Based on our analysis, the indication of aspirin as the first-line choice, also recommended by several acknowledged international or national guidelines, may be confirmed. However, the complex nature of patients at risk of recurrent ischaemic stroke necessitates a comprehensive approach, which should be driven by the primary care physician, whose role is central to successful actions for secondary stroke prevention. [source]

    Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

    Background: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. Methods: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. Results: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. Conclusions: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on [source]

    Administration of blood transfusions to adults in general hospital settings: a review of the literature

    Dip N Ed, John Wilkinson BSc
    ,,The Serious Hazards of Transfusion (SHOT) haemovigilance scheme for the United Kingdom and Republic of Ireland has clearly indicated that there are avoidable risks to which recipients of blood transfusion are exposed. ,,Sometimes errors in practice have led to serious and even fatal consequences, particularly when a haemolytic response occurs due to an incompatible transfusion. ,,Despite the risks, blood transfusion is an important and frequently life-saving therapy and its use in clinical practice is common. ,,This paper discusses recently published national guidelines for the care of recipients of blood transfusion in the light of a review of the literature relevant to the administration of blood transfusions to adults in general hospital settings. ,,Recommendations for practitioners, managers and teachers are offered in relation to preventing errors and to patient care associated with blood transfusion in the context of contemporary emphasis upon evidence based care. [source]

    Adherence to national guidelines on the management of open tibial fractures: a decade on

    Sarvpreet Singh MRCS

    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]

    Prevalence of HBV genotypes in Central and Eastern Europe

    Katja Deterding
    Abstract The importance of hepatitis B virus (HBV) genotypes for disease progression and response to interferon-alpha-based treatment is well established. While almost all patients in the Mediterranean area are infected with HBV genotype D, HBV genotype A is dominant in Northern Europe. However, the distribution of HBV genotypes is unknown for several Central and Eastern European countries. Data are described of 1313 HBsAg-positive patients recruited at 14 referral centers in eight countries. There were only very few cases of HBV genotype B, C, E, F, and H infection while HBV genotypes A and D were found in 42% and 48% of patients, respectively. Eight percent of patients had positive bands for more than one genotype using the hybridization assay. The frequency of genotype A was higher in Poland (77%) and the Czech Republic (67%) as compared to Hungary (47%), Lithuania (41%), Croatia (8%), and Germany (32%). In contrast, HBV genotype D was most frequent in Croatian, Romanian, and Russian patients with 80%, 67%, and 93% of cases, respectively. In conclusion, HBV genotype A versus D showed significantly different distribution patterns in Central and Eastern Europe which deserves consideration for national guidelines and treatment decisions. J. Med. Virol. 80:1707,1711, 2008. © 2008 Wiley-Liss, Inc. [source]

    The use of the nicotine inhaler in smoking cessation

    CCRN (Staff Nurse), Jenny Sigel Burkett RN
    Abstract Purpose: To raise awareness among nurse practitioners (NPs) about the nicotine inhaler by providing clinical and practical information about the use of the nicotine inhaler as a treatment option for smoking cessation. Data sources: This included data-based and review articles in the medical literature, tobacco use and dependence clinical practice guideline, and Medline and Cinahl search engines. Criteria for search keywords were "nicotine inhaler" and "nicotine replacement therapy." Initial search was done in December 2004. Conclusions: The nicotine inhaler has been tested as safe and efficacious in the treatment of tobacco cessation. Clinical trials show the nicotine inhaler to be useful alone or as an adjunct to other pharmacological therapies. Current national guidelines recommend that the nicotine inhaler be used in smoking cessation therapy. Implications for practice: The nicotine inhaler is appropriate for many different smokers, including certain types of cardiac patients. NPs can include the nicotine inhaler in a group of nicotine replacement therapies to ensure that smokers are successful in tobacco cessation. [source]

    Adolescent Obesity: Current Trends in Identification and Management

    M. Anette Hagarty RN
    Purpose To discuss the prevalence, identification, and clinical manifestations of adolescent obesity for the advanced practice nurse in primary care. Data Sources Selected research and clinical articles. Conclusions Adolescent obesity has been historically attributed to inappropriate diet and exercise; however, recent research also attributes adolescent obesity to genetic factors and metabolic dysfunction. If left untreated, adolescent obesity may result in the metabolic complications of dyslipidemia, hypertension, cardiovascular disease, and early onset of type 2 diabetes. Implications for Practice Practitioners should focus on using the new body mass index (BMI) national guidelines for early identification of obesity. Essential to the management of this condition are education, parental involvement, behavior modification, and psychological support. [source]