Published Guidelines (published + guideline)

Distribution by Scientific Domains
Distribution within Medical Sciences

Selected Abstracts

The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches

Fiona M. Clement (Nee Shrive)
Abstract Background: Published guidelines on the conduct of economic evaluations provide little guidance regarding the use and potential bias of the different costing methods. Objectives: Using microcosting and two gross-costing methods, we (1) compared the cost estimates within and across subjects, and (2) determined the impact on the results of an economic evaluation. Methods: Microcosting estimates were obtained from the local health region and gross-costing estimates were obtained from two government bodies (one provincial and one national). Total inpatient costs were described for each method. Using an economic evaluation of sirolimus-eluting stents, we compared the incremental cost,utility ratios that resulted from applying each method. Results: Microcosting, Case-Mix-Grouper (CMG) gross-costing, and Refined-Diagnosis-Related grouper (rDRG) gross-costing resulted in 4-year mean cost estimates of $16,684, $16,232, and $10,474, respectively. Using Monte Carlo simulation, the cost per QALY gained was $41,764 (95% CI: $41,182,$42,346), $42,538 (95% CI: $42,167,$42,907), and $36,566 (95% CI: $36,172,$36,960) for microcosting, rDRG-derived and CMG-derived estimates, respectively (P<0.001). Conclusions: Within subject, the three costing methods produced markedly different cost estimates. The difference in cost,utility values produced by each method is modest but of a magnitude that could influence a decision to fund a new intervention. Copyright 2008 John Wiley & Sons, Ltd. [source]

Depression during pregnancy: detection, comorbidity and treatment

Maria Muzik
Abstract Depression during pregnancy is common (,15%). Routine prenatal depression screening coupled with the use of physician collaborators to assist in connecting women with care is critical to facilitate treatment engagement with appropriate providers. Providers should be aware of risk factors for depression , including a previous history of depression, life events, and interpersonal conflict , and should appropriately screen for such conditions. Depression during pregnancy has been associated with poor pregnancy outcomes including preeclampsia, insufficient weight gain, decreased compliance with prenatal care, and premature labor. Current research has questioned the overall benefit of treating depression during pregnancy with antidepressants when compared to the risk of untreated depression for mother and child. Published guidelines favor psychotherapy above medication as the first line treatment for prenatal depression. Poor neonatal adaptation or withdrawal symptoms in the neonate may occur with fetal exposure in late pregnancy, but the symptoms are mild to moderate and transient. The majority of mothers who decide to stop taking their antidepressants during pregnancy suffer relapsing symptoms. If depression continues postpartum, there is an increased risk of poor mother,infant attachment, delayed cognitive and linguistic skills in the infant, impaired emotional development, and behavioral problems in later life. Bipolar depression, anxiety and substance use disorders, and/or presence of severe psychosocial stress can lead to treatment-resistance. Modified and more complex treatment algorithms are then warranted. Psychiatric medications, interpersonal or cognitive-behavioral therapy, and adjunctive parent,infant/family treatment, as well as social work support, are modalities often required to comprehensively address all issues surrounding the illness. [source]

Serious Bacterial Infections in Febrile Outpatient Pediatric Heart Transplant Recipients

Shan Yin MD
Abstract Objectives:, The purpose of this study was to describe the incidence of serious bacterial infections (SBIs) in febrile outpatient pediatric heart transplant recipients and to assess the utility of using white blood cell (WBC) indices to identify patients at low risk for bacteremia. Methods:, A retrospective study was conducted on all heart transplant recipients followed at a single children's hospital. All outpatient visits from January 1, 1995, to June 1, 2007, in which fever was evaluated were reviewed. Patients with history of a primary immunodeficiency, receiving concurrent chemotherapy, or having had a stem cell or small bowel transplant were excluded. Demographic, historical, physical examination, laboratory, and radiographic data were then recorded. Results:, Sixty-nine patients had 238 individual episodes of fever evaluation; of these, 217 (91.2%) had blood cultures drawn with results available in their initial evaluation. There were six (2.8%) true-positive blood cultures and eight (3.7%) false-positive cultures. Chest radiography was done in 185 evaluations (77.8%), and 44 episodes of pneumonia (23.8%) were diagnosed. Of 112 urine cultures done, one (0.9%) was positive. Neither of two lumbar punctures performed were positive. In non,ill-appearing children without indwelling central lines or focal bacterial infections (pneumonia, cellulitis), the incidence of bacteremia was 1.2%. In children with a focal bacterial infection, the rate of bacteremia was 6.3%. WBC indices were not significantly different between bacteremic and nonbacteremic patients. A band-to-neutrophil ratio (BNR) of ,0.25 and a published guideline for identifying low-risk infants using WBC indices identified all bacteremic patients, each with a sensitivity of 100% (95% confidence interval [CI] = 48% to 100% and 54% to 100%, respectively). Conclusions:, The incidence of bacteremia was low in febrile, outpatient pediatric heart transplant patients, especially in those who were not ill-appearing and did not have a focus of serious infection. Two different low-risk criteria performed well in identifying the bacteremic patients, although given the low number of true-positive cultures, the CIs for the sensitivities of these tests were extremely wide, and neither test could be reliably used at present. A prospective multicenter study is required to confirm the low incidence of bacteremia and low-risk criteria in this population. [source]

National Study on Emergency Department Visits for Transient Ischemic Attack, 1992,2001

Jonathan A. Edlow MD
Abstract Objectives: To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. Methods: The authors obtained data from the 1992,2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. Results: From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). Conclusions: Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation. [source]

Family member presence during resuscitation in the emergency department: An Australian perspective

Bernice Redley
Abstract Objective: The practice of family member presence during resuscitation in the ED has attracted widespread attention over the last few decades. Despite the recommendations of international organizations, clinical staff remain reluctant to engage in this practice in many EDs. This paper separates the evidence from opinion to determine the current state of knowledge about this practice. Methods: A search strategy was developed and used to locate research based publications, which were subsequently reviewed for the strength of evidence providing the basis for recommendations. Results: The literature was examined to reveal what patients and their family members want; the outcomes of family presence during resuscitation for patients and their family members; staff views and practices regarding family presence during resuscitation. Findings suggest that providing the opportunity to be with their critically ill family member is both important to and beneficial for families, however, disparity in staff views has been identified as a major obstacle to family presence during resuscitation. Examination of published guidelines and staff practices described in the literature revealed consistent elements. Conclusion: Although critics point to the lack of rigour in this body of literature, the current state of knowledge suggests merit in pursuing future research to examine and measure effects of family member presence during resuscitation on patients, family members and healthcare providers. [source]

EFNS guidelines on the use of neuroimaging in the management of multiple sclerosis

M. Filippi
Magnetic resonance (MR)-based techniques are widely used for the assessment of patients with suspected and definite multiple sclerosis (MS). However, despite the publication of several position papers, which attempted to define the utility of MR techniques in the management of MS, their application in everyday clinical practice is still suboptimal. This is probably related, not only, to the fact that the majority of published guidelines focused on the optimization of MR technology in clinical trials, but also to the continuing development of modern, quantitative MR-based techniques, that have not as yet entered the clinical arena. The present report summarizes the conclusions of the ,EFNS Expert Panel of Neuroimaging of MS' on the application of conventional and non-conventional MR techniques to the clinical management of patients with MS. These guidelines are intended to assist in the use of conventional MRI for the diagnosis and longitudinal monitoring of patients with MS. In addition, they should provide a foundation for the development of more widespread but rational clinical applications of non-conventional MR-based techniques in studies of MS patients. [source]

Treatment recommendations for chronic hepatitis B: An evaluation of current guidelines based on a natural history study in the United States,

HEPATOLOGY, Issue 4 2008
Myron John Tong
Current guidelines for treatment of chronic hepatitis B include hepatitis B e antigen (HBeAg) status, levels of hepatitis B virus (HBV) DNA, and serum alanine aminotransferase (ALT) values in the setting of either chronic hepatitis or cirrhosis. Based on findings from a prospective study of hepatitis B surface antigen (HBsAg)-positive patients, we determined whether these guidelines included patients who developed hepatocellular carcinoma (HCC) and who died of non-HCC liver-related complications. The criteria for treatment from four published guidelines were matched to a cohort of 369 HBsAg-positive patients enrolled in the study. During a mean follow-up of 84 months, 30 patients developed HCC and 37 died of non-HCC liver-related deaths. Using criteria for antiviral therapy as stated by the four guidelines, only 20%-60% of the patients who developed HCC, and 27%-70% of patients who died of non-HCC liver-related deaths would have been identified for antiviral therapy according to current treatment recommendations. If baseline serum albumin levels of 3.5 mg/dL or less or platelet counts of 130,000 mm3 or less were added to criteria from the four treatment guidelines, then 89%-100% of patients who died of non-HCC liver-related complications, and 96%-100% of patients who developed HCC would have been identified for antiviral therapy. In addition, if basal core promoter T1762/A1764 mutants and precore A1896 mutants also were included, then 100% of patients who developed HCC would have been identified for treatment. Conclusion: This retrospective analysis showed that the current treatment guidelines for chronic hepatitis B excluded patients who developed serious liver-related complications. (HEPATOLOGY 2008.) [source]

Survey of gastroenterologists' awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: Are the guidelines being used and what are the barriers to their use?,

Julianne H. Wagnon MSN
Abstract Background: The American Gastroenterology Association (AGA) published guidelines to assist clinicians in the evaluation and management of osteoporosis in inflammatory bowel disease (IBD) patients. Two studies suggest that when clinicians utilized the guidelines, the majority of their IBD patients were appropriately screened and treated for metabolic bone disease. The aim was to study whether physicians who say they use the AGA Guidelines are, in fact, following the recommendations, and to assess the barriers preventing the use of the guidelines in the management of osteoporosis in their IBD patients. Methods: In all, 1000 physicians were selected from the AGA membership list and mailed a survey inquiring into awareness and implementation of the guidelines on osteoporosis in IBD patients. The barriers to implementation of the guidelines were also assessed. The sum of 21 self-reported clinical practices (absence = 0, presence = 1) was used to evaluate adherence to the guidelines. A value of 0 implied no adherence while a score of 21 meant complete adherence. Results: Of 304 responders, 27 fellows, 8 retirees, and 11 incomplete responses were not included in the analysis; thus, 258 respondents were the subject of this analysis. Slightly less than half of the responders used the guidelines in decision-making (126, 49%) or in the management (110, 42%) of their IBD patients. Using the scoring system described above, clinicians self-reporting use of the guidelines had a significantly higher clinical practice score than those who did not use the guidelines (Wilcoxon rank sum test; P < 0.0001). Only 18% (12 of 68) of clinicians whose practice was comprised of ,25% IBD patients used the guidelines compared to 60% (113/187) physicians who cared for more IBD patients (chi-square test; P < 0.0001). Physicians who saw more IBD patients (>25%) were also more likely (97/187 = 52%) to assess and treat osteoporosis in their IBD patients. Conversely, only 16% (11/68) of physicians who saw ,25% IBD patients treated osteoporosis (chi-square test; P < 0.0001). The main reason physicians (n = 115) gave for not utilizing the guidelines was because they felt that IBD should be the focus of the visit (48, 42%); 34 (30%) reported that osteoporosis should be managed by another physician. Other barriers cited were lack of time (13, 11%), cost (10, 9%), and lack of knowledge (10, 9%). Conclusions: Most of the responding physicians do not utilize the AGA Guidelines on metabolic bone disease in IBD patients. The physicians who self-reported utilizing the guidelines were actually adhering to the recommendations. Further education regarding the impact of metabolic bone disease in IBD patients and the importance of the guidelines is needed, particularly as it addresses the barriers set forth above. (Inflamm Bowel Dis 2009) [source]

Venous thromboembolism in the medically ill patient: a call to action

J.-F. Bergmann
Summary The risk of venous thromboembolism (VTE) in medical patients is generally underestimated. However, recent studies including two large double-blind placebo-controlled trials, the Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilised Patients trial (PREVENT) and prophylaxis in MEDical patients with ENOXaparin, study show that low-molecular-weight heparins (LMWHs) provide effective thromboprophylaxis for medical patients at risk from VTE without increasing the risk of bleeding. In PREVENT the significant 45%, reduction in VTE among patients receiving dalteparin 5000 IU once daily for 14 days was attributed entirely to a reduction in clinically relevant VTE. The recently published guidelines for the prevention and treatment of VTE, issued by the American College of Chest Physicians, recommend prophylaxis with LMWHs (or low-dose unfractionated heparin) in acutely ill medical patients with risk factors for VTE (grade 1A). Current evidence should encourage the more widespread adoption of thromboprophylaxis in at-risk medical patients, and thus reduce the number of preventable deaths and complications due to VTE. [source]

Weight restoration in a patient with anorexia nervosa on dialysis

D. Blake Woodside MD
Abstract Objective We report a case of weight restoration in a patient with anorexia nervosa, end-stage renal disease (ESRD) requiring dialysis, and cardiac insufficiency. Method The technical challenges and ethical issues involved in her clinical management are reviewed. Renal insufficiency is a common complication of more severe anorexia nervosa. Results Progression to renal failure, when it occurs, is most typically a terminal event. There are currently no published guidelines for monitoring the weight gain of patients undergoing dialysis. Conclusion We present a case of a patient who progressed from renal insufficiency to renal failure while in treatment for anorexia nervosa, and who was ultimately successfully weight restored while on renal dialysis. 2005 by Wiley Periodicals, Inc. [source]

Controversies in perioperative management and antimicrobial prophylaxis in urologic surgery

Shingo Yamamoto
Abstract: The Japanese Urological Association (JUA) recently published guidelines for the prevention of perioperative urologic infections. Although the general remarks in the JUA guidelines are almost similar to those in guidelines previously published by the Centers for Disease Control and Prevention (CDC) and in the European Association of Urology (EAU) guidelines, their differences leave several questions that need to be answered. To clarify agreements and differences in guidelines for perioperative management in urologic interventions for development of more optimal guidelines, reports and reviews previously published were overlooked and discussed. In terms of surgical site infections (SSI) in urologic surgery, consensus for open and endoscopic-instrumental procedures is still somewhat controversial, while a consensus has not yet emerged for its use in laparoscopic procedures. Further research is required to determine what is an optimal prophylactic protocol to effectively prevent both SSI and remote infections (RI). [source]

The use of antipyretic medications in the prevention of febrile convulsions in children

Edward Purssell BSc
,,Febrile convulsions are a relatively common outcome in paediatric febrile illness, although it is not known why some children suffer these. ,,Antipyretic medications may form the basis for some treatment regimens, although they are not recommended in published guidelines. ,,There is little evidence that the prophylactic use of antipyretics has any effect in reducing the incidence of febrile convulsions. ,,Consequently, educational interventions aimed at reducing parental fear and helping them to care for their children during febrile illnesses may be more efficacious. [source]

Undertreatment of congestive heart failure in an Australian setting

P. J. Boyles BPharm (Hons)
Summary Aim:, Guidelines for the management of patients with chronic heart failure have undergone change in recent years, with , -blockers and spironolactone shown to reduce mortality when added to angiotensin converting enzyme (ACE) inhibitors, diuretics and digoxin. The aim of this study was to examine the therapeutic management of heart failure in patients admitted to Tasmania's three major public hospitals, with an assessment of the appropriateness of the therapy according to contemporary published guidelines. Methods:, An extensive range of clinical and demographic data was retrospectively extracted from the medical records of consecutive adult patients admitted to the medical wards of the hospitals with heart failure, either as a primary diagnosis or as a comorbidity, during a 6-month period in late 1999,early 2001. Results:, The 450 patients (57% females) had a mean age of 778 102 years, and were being treated with a median of seven drugs on hospital admission. The percentages of patients being treated with the major drugs of interest were: ACE inhibitors (50%), , -blockers (22%), spironolactone (15%), digoxin (24%), loop diuretics (65%) and angiotensin-II receptor antagonists (8%). Almost 10% were taking a non-steroidal anti-inflammatory agent. Less than one-half the patients who were receiving an ACE inhibitor were taking a target dose for heart failure. There were no significant differences in the pattern of drug use between the three hospitals. Underuse of heart failure medications was most pronounced in women and elderly patients. Conclusions:, The data suggest that current guidelines for the treatment of heart failure are still not being reflected in clinical practice. The relatively low use of drugs shown to improve survival in heart failure is of concern and warrants educational intervention. [source]

Culturally centered psychosocial interventions

Guillermo Bernal
Over the last few decades, psychologists and other health professionals have called attention to the importance of considering cultural and ethnicminority aspects in any psychosocial interventions. Although, at present, there are published guidelines on the practice of culturally competent psychology, there is still a lack of practical information about how to carry out appropriate interventions with specific populations of different cultural and ethnic backgrounds. In this article, the authors review relevant literature concerning the consideration of cultural issues in psychosocial interventions. They present arguments in favor of culturally centering interventions. In addition, they discuss a culturally sensitive framework that has shown to be effective for working with Latinos and Latinas. This framework may also be applicable to other cultural and ethnic groups. @ 2006 Wiley Periodicals, Inc. [source]

Communicating and judging the quality of qualitative research: the need for a new language

S. A. Fade
Abstract Background Traditionally UK dietitians have tended to take a more quantitative approach to research. Qualitative research which gives an in-depth view of people's experiences and beliefs is also now being used to help answer some important dietetic research questions. Review A review of the limited number of qualitative research papers in the Journal of Human Nutrition and Dietetics 1990,2002 (nine papers in all), revealed a lack of specific discussion of the quality strategies commonly used in qualitative research. This could indicate a less than robust approach, but might also reflect a different perspective on quality, or simply the difficulties associated with disseminating qualitative research to a profession whose members lack familiarity with the language. The fact that qualitative research seems to be used rarely may also indicate a poor understanding of its role. Purpose of this paper This paper seeks to clarify the potential role of qualitative research and draws on previously published guidelines for demonstrating quality. It is hoped that this will offer dietitians a framework for carrying out qualitative research and a language for reporting it, as well acting as a stimulus for discussion. [source]

Determination of regioselectivity in ring opening of tert -butylaziridinones by a combination of 15N labeling and electrospray ionization-ion trap mass spectrometry

E. R. Talaty
Abstract The ring opening of 1,3-di- tert -butylaziridinone by tert -butylamine and aniline was investigated by using electrospray ionization and collision-induced dissociation in an ion trap mass spectrometer in conjunction with 15N labeling of the two amine nucleophiles. Using the MSn capabilities of the ion trap instrument, we were able to monitor the retention of the 15N label through successive fragmentation steps. Both amines exhibited a remarkable degree of selectivity in that they both cleaved exclusively the 1,3-bond (the alkyl,nitrogen bond). This result is in contrast to that obtained previously with methylamine, which cleaved just the opposite bond, namely, the 1,2-bond (the acyl,nitrogen bond). These contrasting results could not have been predicted by previously published guidelines. Copyright 2001 John Wiley & Sons, Ltd. [source]

Caring for patients with allergic rhinitis

AE-C Nurse Practitioner, APRN-C, Certified Asthma Educator, Clinical Assistant Professor2), Mary Lou Hayden MS
Abstract Purpose: Allergic rhinitis (AR) affects up to 40 million Americans, with an estimated cost of $2.7 billion per annum. This review discusses several therapeutic options that reduce the symptoms of AR, including allergen avoidance, antihistamines, intranasal corticosteroids (INS), leukotriene receptor antagonists, and immunotherapy. Data sources: The articles included in this review were retrieved by a search of Medline literature on the subjects of AR, antihistamines, INS, leukotriene antagonists, and immunotherapy, as well as current published guidelines for the treatment of AR. Conclusions: Allergen avoidance is recommended for all patients prior to pharmacologic therapy. Oral and nasal H1 -antihistamines are recommended to alleviate the mild and intermittent symptoms of AR, and INS are recommended as the first-line treatment choice for mild persistent and more moderate-to-severe persistent AR. Implications for practice: There are a number of different types of therapy for the management of AR; with so many options available, successful tailoring of treatment to suit individual requirements is realistically achievable. [source]

Polycyclic aromatic hydrocarbon residues in the sediments of a dune lake as a result of power boating

Thorsten D. Mosisch
Abstract The potential chemical effects of motorized recreational activities (power boating, water skiing, jet skiing) on Brown Lake, an Australian perched, acid dune lake, were investigated. The objective of this study was to identify and quantify polycyclic aromatic hydrocarbon compounds (PAHs) that may have accumulated in the water and/or the organic bottom sediments of the test lake as a result of the operation of powered recreational watercraft, and to evaluate any risk to aquatic biota. To achieve this, a detailed sampling and analysis programme of the lake water and sediments was implemented. Basic water quality, ionic and nutrient data gave no indication of any deterioration in the water quality of the lake, which was attributable to human usage in general or motorized recreational activities in particular. However, analysis of samples taken from the organic bottom sediments of the lake revealed the presence of 10 PAH, including benzo(a)pyrene, chrysene, fluoranthene, phenanthrene and pyrene, which are known to be indicative of fossil fuel combustion processes. Three PAH compounds were found at all survey sites: benzo(a)pyrene (in 46% of samples), fluoranthene (in 53% of samples) and pyrene (in 44% of samples). Results of the analyses were compared with values from published guidelines for residues in freshwaters and sediments, as well as with previous studies dealing with the effects of fossil fuel combustion products on lakes. The highest PAH concentrations in sediments were recorded for benzo(a)pyrene, with three values (830, 955 and 1070 ,g kg,1 dryweight) exceeding the upper threshold recommended in the draft Canadian freshwater sediment quality guidelines. Benzo(a)pyrene also exceeded the lower Canadian sediment threshold in 51 (40%) samples. These results indicate a significant level of chemical contamination of Brown Lake as a consequence of four decades of motorized recreational activities and present a significant risk to aquatic biota, particularly benthic and littoral invertebrates associated with the contaminated sediments. [source]

Review article: appropriate use of corticosteroids in Crohn's disease

Summary Background, Corticosteroids are a well-established treatment for active Crohn's disease and have been widely used for decades. It has become apparent, however, that a proportion of patients either fails to respond to corticosteroids or is unable to withdraw from them without relapsing. Furthermore, their use is associated with a range of side effects, such that long-term treatment carries unacceptable risk. Aim, To review the evidence regarding the appropriate use of corticosteroids in Crohn's disease, along with their side effects, safety and alternatives. Methods, To collect relevant articles, a PubMed search was performed from 1966 to November 2006 using the terms ,steroid', ,corticosteroid', ,glucocorticoid', ,prednisolone', ,prednisone', ,methylprednislone', ,hydrocortisone', ,dexamethasone' and ,budesonide' in combination with ,Crohn(s) disease'. Relevant articles were reviewed, as were their reference lists to identify further articles. Results, When used correctly, corticosteroids are a highly effective, well tolerated, cheap and generally safe treatment for active Crohn' disease. Nevertheless, approximately 50% of recipients will either fail to respond (steroid-resistant) or will be steroid dependent at 1 year. Newer alternatives to corticosteroids are not, however, without risk themselves and, moreover, are not necessarily available universally. Conclusions, Steroids are used widely to treat Crohn's disease, a situation that is unlikely to change in the near future. Accordingly, efforts should be made to ensure that they are used correctly and that their side effects are minimized. Reference is made to recently published guidelines and a simplified ,users guide' is presented. [source]

Impact of Helicobacter pylori on the management of dyspepsia in primary care

Summary Background, It is unclear what impact Helicobacter pylori infection has had on the management of dyspepsia in primary care and to what extent published guidelines on H. pylori are implemented in routine clinical practice. Aim, To assess the impact of H. pylori infection on the management of dyspepsia in primary care. Methods, Patients referred by primary care doctors to an open-access 13-carbon urea breath test service over a 2-year period for their first urea breath test were included in the study. Individual breath results were linked with data on prescribing obtained from the General Medical Services prescription database. Results, Of 805 patients, 374 (47%) had a positive urea breath test and 431 (54%) a negative urea breath test. Of positive urea breath test patients, only 245 (64%) were prescribed eradication therapy in the 3 months after the breath test and only 43% were referred back for re-testing. In the year after the urea breath test, there was a significant fall in prescribing of antisecretory therapy which was greatest in the patients who received H. pylori therapy (P < 0.001). Conclusions, There appears to be under and inappropriate treatment of H. pylori infection in primary care, and a low rate of re-testing after eradication, indicating that current guidelines are not well implemented in practice. [source]

Use of the DirecNet Applied Treatment Algorithm (DATA) for diabetes management with a real-time continuous glucose monitor (the FreeStyle Navigator)

Diabetes Research In Children Network (DirecNet) Study Group
Background:, There are no published guidelines for use of real-time continuous glucose monitoring data by a patient; we therefore developed the DirecNet Applied Treatment Algorithm (DATA). The DATA provides algorithms for making diabetes management decisions using glucose values: (i) in real time which include the direction and rate of change of glucose levels, and (ii) retrospectively based on downloaded sensor data. Objective:, To evaluate the use and effectiveness of the DATA in children with diabetes using a real-time continuous glucose sensor (the FreeStyle Navigator). Subjects:, Thirty children and adolescents (mean standard deviation age = 11.2 4.1 yr) receiving insulin pump therapy. Methods:, Subjects were instructed on use of the DATA and were asked to download their Navigator weekly to review glucose patterns. An Algorithm Satisfaction Questionnaire was completed at 3, 7, and 13 wk. Results:, At 13 wk, all of the subjects and all but one parent thought that the DATA gave good, clear directions for insulin dosing, and thought the guidelines improved their postprandial glucose levels. In responding to alarms, 86% of patients used the DATA at least 50% of the time at 3 wk, and 59% reported doing so at 13 wk. Similar results were seen in using the DATA to adjust premeal bolus doses of insulin. Conclusions:, These results show the feasibility of implementing the DATA when real-time continuous glucose monitoring is initiated and support its use in future clinical trials of real-time continuous glucose monitoring. [source]

Combination treatment of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus

AN Dixon MRCP (UK) Clinical Research FellowArticle first published online: 7 DEC 200
Abstract The recently published guidelines from the National Institute for Clinical Excellence (NICE) on the management of blood glucose in type 2 diabetes and the NICE guidelines on the use of the long-acting insulin analogue, glargine, have brought to the fore the use of combination therapy of insulin with oral hypoglycaemic agents (OHAs). The NICE guidelines recommend that when a patient with type 2 diabetes is failing to achieve satisfactory glycaemic control with OHAs alone, insulin should be initiated in combination with OHAs. However, evidence for this approach is less than robust and combination treatment of OHAs with insulin remains a controversial area. This article presents the evidence for different insulin regimens in patients who have secondary failure to OHAs, including combination therapy with basal insulin. The evidence and potential drawbacks of such regimens are discussed. Copyright 2004 John Wiley & Sons, Ltd. [source]

Lost in transition: Challenges in the expanding field of adult genetics,

Matthew R.G. Taylor
Abstract It is increasingly clear that medical genetics has broad relevance in adult clinical medicine. More adult patients with genetic conditions are being recognized, genetic testing for adult-onset genetic conditions is expanding, and children with genetic conditions are now more likely to survive to adulthood. While the number of patients who could benefit from medical genetic services increases, adult care providers are less well educated about clinical genetics and are not sufficiently prepared to meet the growing needs of this population. Genetics professionals may also be ill-suited for this challenge, since geneticists and genetic counselors have traditionally had greater experience in pediatric and prenatal settings. Communication between primary care physicians who treat adults and the genetics community is currently suboptimal and the identification and subsequent referral of adult patients for genetic services need improvement. Finally, published guidelines that address how to deliver genetic services to adult patients are unavailable for many genetic conditions. In this article we address the challenges of transitioning genetics services from traditional, and largely pediatric-based models to paradigms that can best address the needs of adult patients with genetic conditions. Potential solutions and the practicality of implementation of a team-based approach to adult genetic medicine, including the application of genetic counseling, are also discussed. 2006 Wiley-Liss, Inc. [source]

Comments on the IPC Surface Mount Attachment Reliability Guidelines

Olli Salmela
Abstract The Institute for Interconnecting and Packaging Electronic Circuits (IPC) has published guidelines and standards related to surface mount solder attachments. The latest standard IPC-9701 was published in 2002. In this paper, the general methodology for creating the aforementioned documents and the related qualification requirements are reviewed and discussed. Also, corrections to the standards and guidelines are proposed. The corrections are related both to the use of formulas and to inaccuracies in the units used. Copyright 2005 John Wiley & Sons, Ltd. [source]

Practitioner Review: The contribution of attachment theory to child custody assessments

James G. Byrne
Background:, The area of child custody assessments continues to fail to meet the evidence-based threshold now established in clinical practice. This is despite the existence, for many years, of published guidelines governing the practice of custody assessments available from a number of professional bodies. Methods:, This article reviews the potential of attachment theory to contribute to the conceptualization of custody evaluations, clinical assessment, and the development of evidence-based practice. Particular attention is paid to specific instruments used to assess attachment in clinic and non-clinic settings. Results:, Guidelines concerning child custody assessments highlight the particular importance of assessing attachment and parent,child relationship quality. However, measures often used in the course of a custody assessment are not backed up with empirical research, and the measures that are supported by empirical research have been slow to influence practice. There may be conceptual and measurement advantages of considering an attachment research-informed custody assessment. Discussion:, Attachment theory has obvious conceptual relevance for the child custody context. Further clinical research is needed to demonstrate the usefulness of attachment research measures; research of this kind may shed important light on the development and resilience of affectional bonds. [source]

Design and implementation of training to improve management of pediatric overweight

Continuing Medical Education, Luke Beno MD Chief
Abstract Introduction: Clinicians report a low proficiency in treating overweight children and using behavioral management strategies. This paper documents the design and implementation of a training program to improve clinicians' skills in the assessment and behavioral management of pediatric overweight. Methods: Two one-hour CME trainings were designed using published guidelines, research findings, and expert committee recommendations. The trainings were provided to clinicians of a managed care pediatric department, utilizing novel screening and counseling tools, and interactive exercises. Surveys and focus groups were conducted 3 and 6 months post intervention to examine clinician attitudes and practices regarding the screening and counseling tools. Results: Post intervention, the majority of clinicians agreed that the clinical practice guidelines (Pediatric Obesity Practice Resource) and BMI-for-age percentile provided useful information for clinical practice. Clinicians reported an increased utilization of the recommended screening tools and changes in office practices to implement these tools. They offered suggestions to improve the ease of use of the tools and to overcome perceived clinician and/or patient barriers. Discussion: A brief, cost effective, multi-faceted training and provision of counseling tools were perceived as helpful to clinical practice. Useful lessons were learned about tool design and ways to fit tools into practice. Training the entire health care team is advantageous to the adoption of new tools and practices. [source]

The formulation and introduction of a ,can't intubate, can't ventilate' algorithm into clinical practice

ANAESTHESIA, Issue 6 2009
A. M. B. Heard
Summary Both the American Society of Anesthesiologists and the Difficult Airway Society of the United Kingdom have published guidelines for the management of unanticipated difficult intubation. Both algorithms end with the ,can't intubate, can't ventilate' scenario. This eventuality is rare within elective anaesthetic practice with an estimated incidence of 0.01,2 in 10 000 cases, making the maintenance of skills and knowledge difficult. Over the last four years, the Department of Anaesthetics at the Royal Perth Hospital have developed a didactic airway training programme to ensure staff are appropriately trained to manage difficult and emergency airways. This article discusses our training programme, the evaluation of emergency airway techniques and subsequent development of a ,can't intubate, can't ventilate' algorithm. [source]

Antibiotic-treated infections in intensive care patients in the UK

ANAESTHESIA, Issue 9 2004
B. H. Cuthbertson
Summary The purpose of this audit was to study reasons for starting antibiotic therapy, duration of antibiotic treatment, reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice. We conducted a multicentre observational audit of 316 patients. Data on demographic details, site, treatment and nature of infection were collected. The median duration of antibiotic therapy was 7 days. Infections were community-acquired in 160 patients (55%). Antibiotics were started on clinical suspicion of infection in 237 patients (75%). Pulmonary infections were the most common, representing 52% of all proven infections. Gram-negative organisms were the most common cause of proven infections (n = 90 (50%)). The antibiotic spectrum was narrowed in light of microbiology results in 78 patients (43%) and changed due to antibiotic resistance in 38 patients (21%). We conclude that the mean duration of treatment contrasts with existing published guidelines, highlighting the need for further studies on duration and efficacy of treatment in intensive care. [source]

Re-use of equipment between patients receiving total intravenous anaesthesia: a postal survey of current practice,

ANAESTHESIA, Issue 6 2003
M. J. Halkes
Summary In order to establish current practice with regard to the reuse of infusion equipment between patients receiving total intravenous anaesthesia (TIVA), a postal survey of 393 consultants was carried out. Additionally, consultants' awareness of relevant guidelines was assessed. Overall, 46% of consultants change all equipment between cases, 37% change one-way valves and 17% change distal lengths of the infusion tubing. Only 13% of consultants reported knowledge of any guidelines. In the absence of any data relevant to the current techniques of administering TIVA, the level of risk associated with the reuse of infusion components is impossible to quantify. Disposal of all equipment between cases incurs a 26% greater cost when compared to changing one-way valves alone. Variation in practice between consultants creates the potential for system errors. Practice should be standardised and, to comply with the published guidelines, should involve disposal of all equipment between cases. [source]

Availability of antidotes for the treatment of acute poisoning in Queensland public hospitals

Lisa M. Nissen
Abstract Objective:,To determine the sufficiency of stock levels of 13 antidotes in Queensland hospitals. Design:,A self-report survey was sent to 128 Queensland hospitals with acute care facilities. The stock level of the following antidotes was determined: acetylcysteine, anti-digoxin Fab antibodies (digibind), atropine, calcium gluconate, cyanokit, desferrioxamine, flumazenil, glucagon, intravenous ethanol, methylene blue, naloxone, pralidoxime and pyridoxine. Other factors sampled were bed capacity, rural, remote and metropolitan areas classification, use of formal stock reviews by pharmacists or nurses, existence of formal borrowing agreements with other facilities for non-stocked antidotes, distance to the nearest referral hospital and time taken to transfer antidotes from another hospital. Participants:,Pharmacists or nurses responsible for maintaining antidote stocks in Queensland hospitals. Main outcome measures:,Proportions of hospitals with sufficient antidote stock to treat a 70-kg adult for four or more hours using previously published guidelines. Results:,Survey response rate was 73.4%. No hospital had sufficient stock of all 13 antidotes. The proportion of hospitals with sufficient stocks varied from 0% (pyridoxine) to 68.1% (acetylcysteine). Larger hospitals had a higher frequency of sufficient antidote stocks. Only 16% of hospitals claimed to be able to acquire an antidote from another facility within 30 min. Conclusions:,Most Queensland hospitals stocked some important antidotes, but few had sufficient stock to treat a 70-kg patient or acquire an antidote within the recommended time frame of 30 min. Specific antidote stocking guidelines might be required for Queensland hospitals. A formalised program for stock rotation with rural facilities should be explored. [source]