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Clear Guidelines (clear + guideline)
Selected AbstractsPaediatric antibiotic prescribing by general dental practitioners in EnglandINTERNATIONAL JOURNAL OF PAEDIATRIC DENTISTRY, Issue 4 2001N.O.A. Palmer Objectives. The inappropriate use of antibiotics is known to be a major contributory factor to the problem of antimicrobial resistance. No information is available on how practitioners prescribe antibiotics for children. This study investigated the prescribing of liquid-based antibiotics for children by general dental practitioners in England. Design. Analysis of National Health Service liquid-based prescriptions issued by general dental practitioners in England. Sample and methods. All prescriptions issued by practitioners in 10 Health Authorities in England for February 1999 were collected. All the liquid-based antibiotic prescriptions for children were selected and we investigated the type of antibiotic prescribed, whether sugar free, the dose, frequency and duration. Results. A total of 18614 prescriptions were issued for antibiotics. Of the 1609 liquid-based paediatric prescriptions 88·3% were for generic and 11·7% for proprietary antibiotics, of which 75·5% were for amoxicillin, 15·2% for phenoxymethylpenicillin, 6·6% for erythromycin, 1·7% for metronidazole. Cephalexin, ampicillin, cephadrine and combinations of two antibiotics were also prescribed. There was a wide variation in dosages for all the antibiotics prescribed. A significant proportion of practitioners prescribed at frequencies inconsistent with manufacturers' recommendations and for prolonged periods, with some practitioners prescribing for periods up to 10 days. Only 29·1% of all the prescriptions issued were sugar free. Conclusions. The results of this study show that some practitioners prescribe liquid-based antibiotics inappropriately for children. This may contribute to the problem of antimicrobial resistance. Clear guidelines on the choice of antibiotic, dose, frequency and duration along with educational initiatives for GDPs might reverse this trend. [source] Sexual and gender minority therapy and systemic practiceJOURNAL OF FAMILY THERAPY, Issue 4 2009Catherine Butler While there has been an increase in papers addressing working with lesbian and gay clients over the past two decades, this paper builds on this historical context to combine the latest developments in therapy with sexual and gender minority clients with principles of systemic theory and practice. Clear guidelines are provided on how to apply sexual and gender minority therapy within a systemic frame. Specific issues relating to sexual and gender minority couple and family work are addressed, with the provision of further suggestions and resources. [source] Alcohol and lactation: A systematic reviewNUTRITION & DIETETICS, Issue 2 2006Roslyn GIGLIA Abstract The aim of the present paper is to critically review the current literature on the effect of alcohol intake during lactation on the hormonal control of lactogenesis; breast milk and infant blood alcohol concentration; and on the breastfeeding infant. The databases PubMed, CINAHL, Proquest Health and Medical Complete, ScienceDirect and ISI Web of Knowledge were searched for articles published between 1990 and 2005. We found limited research investigating the effect of alcohol intake on the infants of lactating women, with most being conducted using animal models. Results consistently show a decrease in lactational performance in both animal and human studies of alcohol intake and breastfeeding. Alcohol intake by lactating mothers in amounts recommended as ,safe' for non-lactating women may have a negative effect on infant development and behaviour. Clear guidelines for alcohol consumption are required for lactating women and health professionals to guide breastfeeding mothers to make educated choices regarding alcohol intake during this critical period of infant development. [source] Polyamides nanocapsules: Modeling and wall thickness estimationAICHE JOURNAL, Issue 6 2006K. Bouchemal Abstract This work provides a better understanding for effective control of the nanocapsules wall thickness. Polyamides based nanocapsules are prepared by interfacial polymerization combined with spontaneous emulsification. A clear guideline of how factors such as monomer concentration, diffusion, interfacial reaction, or water swelling influence the capsule formation is very important to the control of capsule wall structure and release performance. In this goal, the macroscopic planar models of the interfacial polycondensation between diethylenetriamine and sebacoyle chloride are studied experimentally and theoretically. This planar model is developed to examine the kinetics of the reaction and to perform the estimation of parameters thanks to the experiment measurements. The effect of the operating conditions on the wall thickness is also studied. The model is shown to be consistent with the experimental data. Next, the spherical model is deduced from the first one. The results obtained with this model are in accordance with some observations of wall thickness. From this model, the increase of the wall thickness is predicted for several operating conditions. © 2006 American Institute of Chemical Engineers AIChE J, 2006 [source] Atrophy and anarchy: third national survey of nursing skill-mix and advanced nursing practice in ophthalmologyJOURNAL OF CLINICAL NURSING, Issue 12 2006Dip Nursing, Wladyslawa J. Czuber-Dochan MSc Aims and objectives., The aims of the study were to investigate the advanced nursing practice and the skill-mix of nurses working in ophthalmology. Background., The expansion of new nursing roles in the United Kingdom in the past decade is set against the background of a nursing shortage. The plan to modernize the National Health Service and improve the efficiency and delivery of healthcare services as well as to reduce junior doctors' hours contributes towards a profusion of new and more specialized and advanced nursing roles in various areas of nursing including ophthalmology. Design., A self-reporting quantitative questionnaire was employed. The study used comparative and descriptive statistical tests. Method., The questionnaires were distributed to all ophthalmic hospitals and units in the United Kingdom. Hospital and unit managers were responsible for completing the questionnaires. Results., Out of a total 181 questionnaires 117 were returned. There is a downward trend in the total number of nurses working in ophthalmology. The results demonstrate more nurses working at an advanced level. However, there is a general confusion regarding role interpretation at the advanced level of practice, evident through the wide range of job titles being used. There was inconsistency in the qualifications expected of these nurses. Conclusion., Whilst there are more nurses working at an advanced level this is set against an ageing workforce and an overall decline in the number of nurses in ophthalmology. There is inconsistency in job titles, grades, roles and qualifications for nurses who work at an advanced or higher level of practice. The Agenda for Change with its new structure for grading jobs in the United Kingdom may offer protection and consistency in job titles, pay and qualifications for National Health Service nurse specialists. The Nursing and Midwifery Council needs to provide clear guidelines to the practitioners on educational and professional requirements, to protect patients and nurses. Relevance to clinical practice., The findings indicate that there is a need for better regulations for nurses working at advanced nursing practice. [source] Early versus late enteral nutritional support in adults with burn injury: a systematic reviewJOURNAL OF HUMAN NUTRITION & DIETETICS, Issue 2 2007J. Wasiak Abstract Background Burn injury increases the body's metabolic demands, and therefore nutritional requirements. Provision of an adequate supply of nutrients is believed to lower the incidence of metabolic abnormalities, thus reducing septic morbidity, and improving survival rates. Enteral nutrition support is the best feeding method in a patient who is unable to achieve an adequate oral intake, but optimal timing of its introduction after burn injury (i.e. early versus late) needs to be established. The purpose of this review is to examine evidence for the effectiveness and safety of early versus late enteral nutrition support in adults with burn injury. Methods An examination of randomized and controlled clinical trials using various medical databases such as The Cochrane Library (Issue 3, 2006), MEDLINE (from 1950), CINHAL (from 1982) and EMBASE (from 1980). Results The trial evidence about the benefit of early enteral nutritional support on standardized clinical outcomes such as length of hospital stay and mortality remained inconclusive. Similarly, the question of whether early enteral feeding influenced or decreased metabolic rate, reduced septic and other complications remained uncertain. Conclusions Promising results suggest early enteral nutrition support may blunt the hypermetabolic response to thermal injury, but it is insufficient to provide clear guidelines for practice. Further research incorporating larger sample sizes and rigorous methodology that utilizes valid and reliable outcome measures is essential. [source] Teamwork in primary care mental health: a policy analysisJOURNAL OF NURSING MANAGEMENT, Issue 6 2008BSc (Hons), Dip HE (Mental Health Nursing), ELOISE NOLAN MSc Aim, This paper reports a policy analysis conducted to examine the potential impact of recent mental health policy on team working in Primary Care Mental Health in England. Method, An analysis of relevant policy documents was conducted. From an original selection of 49 documents, 15, which had significant implications for Primary Care Mental Health Teams, were analysed thematically. Findings, There were no clear guidelines or objectives for Primary Care Mental Health Teams evident from the policy analysis. Collaborative working was advocated, yet other elements in the policies were likely to prevent this occurring. There was a lack of clarity concerning the role and function of new professions within Primary Care Mental Health Teams, adding further uncertainty to an already confused situation. Conclusion, This uncertainty has the potential to reinforce professional barriers and increase the current difficulties with team working. Implications to nursing managers, An analysis of recent policy contributes to our understanding of the context of care. The lack of clarity in current health policy presents a significant challenge for those managing primary care mental health teams. Team working is likely to improve if targets, processes and responsibilities are made clearer. [source] Targeted mechanical properties for optimal fluid motion inside artificial bone substitutesJOURNAL OF ORTHOPAEDIC RESEARCH, Issue 8 2009L.D. Blecha Abstract Our goal was to develop a method to identify the optimal elastic modulus, Poisson's ratio, porosity, and permeability values for a mechanically stressed bone substitute. We hypothesized that a porous bone substitute that favors the transport of nutriments, wastes, biochemical signals, and cells, while keeping the fluid-induced shear stress within a range that stimulates osteoblasts, would likely promote osteointegration. Two optimization criteria were used: (i) the fluid volume exchange between the artificial bone substitute and its environment must be maximal and (ii) the fluid-induced shear stress must be between 0.03 and 3 Pa. Biot's poroelastic theory was used to compute the fluid motion due to mechanical stresses. The impact of the elastic modulus, Poisson's ratio, porosity, and permeability on the fluid motion were determined in general and for three different bone substitute sizes used in high tibial osteotomy. We found that fluid motion was optimized in two independent steps. First, fluid transport was maximized by minimizing the elastic modulus, Poisson's ratio, and porosity. Second, the fluid-induced shear stress could be adjusted by tuning the bone substitute permeability so that it stayed within the favorable range of 0.03 to 3 Pa. Such method provides clear guidelines to bone substitute developers and to orthopedic surgeons for using bone substitute materials according to their mechanical environment. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 1082,1087, 2009 [source] Guidelines for Managing Life-Threatening Food Allergies in Massachusetts SchoolsJOURNAL OF SCHOOL HEALTH, Issue 5 2004Anne H. Sheetz ABSTRACT: During the past decade, prevalence of food allergies among children increased. Caring for children with life-threatening food allergies has become a major challenge for school personnel. Prior to 2002, Massachusetts did not provide clear guidelines to assist schools in providing a safe environment for these children and preparing for an emergency response to unintended allergic reactions. In 2001, the Asthma and Allergy Foundation of America/New England Chapter, Massachusetts Department of Education, Massachusetts Department of Public Health, Massachusetts School Nurse Organization, parents, and other professional organizations forged a successful collaboration to develop guidelines for managing life- threatening food allergies in schools. The guidelines assist schools by providing information on food allergies and anaphylaxis, emphasizing the need for team planning and development of an individualized health care plan, giving guidance on strategies to prevent accidental exposure to specific allergens in school settings, and offering information on emergency responses should unintended exposures occur. The collaborative process for developing the guidelines, which continued during the distribution and implementation phases, set a tone for successful multidisciplinary teamwork in local schools. [source] Use of preventive measures for air travel-related venous thrombosis in professionals who attend medical conferencesJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 11 2006S. KUIPERS Summary.,Background:,Lack of guidelines for prevention of air travel-related venous thrombosis may lead to excessive use of potentially dangerous precautions. Objectives:,To assess the use of preventive measures for air travel-related thrombosis in professionals employed in the field of thrombosis and hemostasis and in other fields. Methods:,A survey amongst delegates of the XXth ISTH Congress, the 15th ISDB Congress and the 13th Cochrane Colloquium, which all took place in Australia 2005. Results:,Two thousand and eighty-nine questionnaires were completed (response 53%). Overall, 80% of the respondents had used preventive measures. Low-molecular-weight heparin and vitamin K antagonists were mostly used by ISTH delegates (10% vs. 1% at the other conferences). Medical doctors used more pharmacological prophylaxis (31%) than research fellows (11%) and non-clinical scientists (22%). Dutch (64%) and Asian respondents (67%) least used any prevention, whereas Israeli used most (94%). Subjects with risk factors for thrombosis more often used prophylaxis (90%) than those without (77%). In a multivariate analysis, conference, nationality, age, presence of risk factors and profession were determinants of prophylaxis use. Conclusion:,Major differences in the use of prophylactic measures for air travel-related thrombosis stress the need for studies of interventions and clear guidelines on prevention of air travel-related venous thrombosis. [source] Infant feeding in the neonatal unitMATERNAL & CHILD NUTRITION, Issue 4 2010Rhona J. McInnes Abstract Infants admitted to a neonatal unit (NNU) are frequently unable to feed by breast or bottle because of ill health or prematurity. These infants require nutritional support until they can start oral feeding. Breastfeeding is advocated for these infants, and mothers are frequently encouraged to express breast milk to be fed via the enteral tube. However, by discharge, breastfeeding rates tend to be low. Oral feeding requires careful management, and although practices may vary because of clinical need, some may be informed by unit norms. There is limited evidence for effective breastfeeding support in this environment and little exploration of the effect of routine feeding decisions. This study aimed to explore feeding decisions and considered how these might affect outcomes. The staff in the two large urban NNUs who participated in the feeding decisions were interviewed and the data were analysed using a theoretical framework. Feeding decisions were made mainly by the unit staff, with limited parental involvement. Subsequent management varied, with differences being related to staff experience and beliefs, unit norms, parent's expectations and physical constraints within the unit. The staff were overtly supportive of breastfeeding, but the need to monitor and quantify milk intake may undermine breastfeeding. Furthermore, feeding breastfed infants during the mothers' absence was controversial and provoked debate. There is a need for clear guidelines and increased parental involvement in feeding decisions. Routine practices within the system may discourage mothers from initiating and persisting with breastfeeding. A change in unit culture is required to fully support the parent's feeding choices. [source] Practitioner Review: When parent training doesn't work: theory-driven clinical strategiesTHE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES, Issue 12 2009Stephen Scott Improving the parent,child relationship by using strategies based on social learning theory has become the cornerstone for the treatment of conduct problems in children. Over the past 40 years, interventions have expanded greatly from small, experimental procedures to substantial, systematic programmes that provide clear guidelines in detailed manuals on how practitioners should implement the standardised treatments. They are now widely disseminated and there is a great deal of empirical support that they are very effective for the majority of cases. However, evaluations of even the best of these evidence-based programmes show that a quarter to a third of families and their children do not benefit. What does the practitioner then do, when a standard social learning approach, diligently applied, doesn't work? We argue that under these circumstances, some of the major theories of child development, family functioning and individual psychology can help the skilled practitioner think his or her way through complex clinical situations. This paper describes a set of practical strategies that can then be flexibly applied, based on a systematic theoretical analysis. We hold that social learning theory remains the core of effective parent training interventions, but that ideas from attachment theory, structural family systems theory, cognitive-attribution theory, and shared empowerment/motivational interviewing can each, according to the nature of the difficulty, greatly enrich the practitioner's ability to help bring about change in families who are stuck. We summarise each of these models and present practical examples of when and how they may help the clinician plan treatment. [source] Emergency Medicine in the Developing World: A Delphi StudyACADEMIC EMERGENCY MEDICINE, Issue 7 2010Peter W. Hodkinson MPhil(EM) ACADEMIC EMERGENCY MEDICINE 2010; 17:765,774 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, Emergency medicine (EM) as a specialty has developed rapidly in the western world, but remains largely immature in developing nations. There is an urgent need for emergency services, but no clear guidelines are available on the priorities for establishing EM in the developing world. This study seeks to establish consensus on key areas of EM development in developing world settings, with respect to scope of EM, staffing needs, training requirements, and research priorities. Methods:, A three-round Delphi study was conducted via e-mail. A panel was convened of 50 EM specialists or equivalent, with experience in or interest in EM in the developing world. In the first round, panelists provided free-text statements on scope, staffing, training, and research priorities for EM in the developing world. A five-point Likert scale was used to rate agreement with the statements in Rounds 2 and 3. Consensus statements are presented as a series of synopsis statements for each of the four major themes. Results:, A total of 168 of 208 statements (81%) had reached consensus at the end of the study. Key areas in which consensus was reached included EM being a specialist-driven service, with substantial role for nonphysicians. International training courses should be adapted to local needs. EM research in developing countries should be clinically driven and focus on local issues of importance. Conclusions:, The scope and function of EM and relationships with other specialties are defined. Unambiguous principles are laid out for the development of the specialty in developing world environments. The next step required in this process is translation into practical guidelines for the development of EM in developing world settings where they may be used to drive policy, protocols, and research. [source] Opioid switching from transdermal fentanyl to oral methadone in patients with cancer painCANCER, Issue 12 2004Miguel Angel Benítez-Rosario M.D., Ph.D. Abstract BACKGROUND Patients with cancer often are rotated from other opioids to methadone to improve the balance between analgesia and side effects. To the authors' knowledge, no clear guidelines currently exist for the safe and effective rotation from transdermal fentanyl to methadone. METHODS The authors evaluated a protocol for switching opioid from transdermal fentanyl to oral methadone in 17 patients with cancer. Reasons for switching were uncontrolled pain (41.1% of patients) and neurotoxic side effects (58.9% of patients). Methadone was initiated 8,24 hours after fentanyl withdrawal, depending on the patient's previous opioid doses (from < 100 ,g per hour to > 300 ,g per hour). The starting methadone dose was calculated according to a 2-step conversion between transdermal fentanyl:oral morphine (1:100 ratio) and oral morphine:oral methadone (5:1 ratio or 10:1 ratio). The correlation between previous fentanyl dose and the final methadone dose or the fentanyl:methadone dose ratio was assessed by means of Pearson and Spearman correlation coefficients (r), respectively. A Friedman test was used to compare pain intensity before and after the switch and the use of daily rescue doses. RESULTS Opioid rotation was fully or partially effective in 80% and 20%, respectively, of patients with somatic pain. Neuropathic pain was not affected by opioid switching. Delirium and myoclonus were reverted in 80% and 100% of patients, respectively, after opioid switching. A positive linear correlation was obtained between the fentanyl and methadone doses (Pearson r, 0.851). Previous fentanyl doses were not correlated with the final fentanyl:methadone dose ratios (Spearman r, , 0.327). CONCLUSIONS The protocol studied provided a safe approach for switching from transdermal fentanyl to oral methadone, improving the balance between analgesia and side effects in patients with cancer. Cancer 2004. © 2004 American Cancer Society. [source] Older age predicts a decline in adjuvant chemotherapy recommendations for patients with breast carcinomaCANCER, Issue 9 2003Evidence from a tertiary care cohort of chemotherapy-eligible patients Abstract BACKGROUND The appropriate use of adjuvant chemotherapy for elderly women with breast carcinoma remains controversial. Efficacy data in women age , 70 years are scarce, resulting in a lack of clear guidelines for patients in this age group. Although several studies have demonstrated decreasing use of chemotherapy with age, none specifically examined its use in an elderly cohort of patients who were deemed eligible for such therapy based on consensus guidelines, simultaneously examining the impact of comorbidity and previous history of malignant disease on these recommendations. METHODS The authors examined adjuvant chemotherapy use among chemotherapy-eligible patients age , 50 years who were evaluated in a tertiary care cancer center. Associations between patient age and 1) physician recommendation for adjuvant chemotherapy, 2) recommended treatment regimen, and 3) patient acceptance of the treatment plan recommended were examined, adjusting for the impact of aggressive tumor characteristics, medical comorbidity, previous history of malignant disease, and features of the treatment setting. RESULTS Of the 208 chemotherapy-eligible patients who were studied, 74% overall were recommended chemotherapy. Chemotherapy was recommended to 92% of women age 50,59 years compared with 77% of women age 60,69 years and 23% of women age , 70 years. Increasing age was associated strongly with a decreasing likelihood of receiving a recommendation in favor of chemotherapy. After adjusting for estrogen receptor status, previous history of malignant disease, comorbidity score, and prognostic group, the odds of receiving a recommendation in favor of chemotherapy fell by 22% per year or 91% per 10-year interval, and the rate of decline did not change significantly at age , 70 years. We found no age-related differences in either the drug regimens recommended or patient acceptance rates for adjuvant therapy. CONCLUSIONS Age was associated strongly and independently with physician recommendation for adjuvant chemotherapy among a group of older women who were eligible specifically for such therapy. Medical comorbidity and a history of previous malignant disease did not alter this correlation significantly, although the latter was a significant predictor of chemotherapy use. Further studies clearly are needed to determine the underlying reasons for this strong age effect and to explore strategies that will optimize the utilization of this potentially curative therapy in the elderly. Cancer 2003;97:2150,9. © 2003 American Cancer Society. DOI 10.1002/cncr.11338 [source] Maximizing management of patients with decompensated heart failureCLINICAL CARDIOLOGY, Issue S3 2000E. Loh M.D. Abstract Patients with decompensated congestive heart failure can be categorized into those with either acute or chronic presentations. Patients with acute decompensated heart failure most often have an acute injury that affects either myocardial performance (i.e., myocardial infarction) or valvular/chamber integrity (mitral regurgitation, ventricular septal rupture), which leads to an acute rise in left ventricular (LV) filling pressures resulting in pulmonary edema and dyspnea. Therapy for these patients is aimed at treating the underlying cause of the myocardial injury as well as pharmacologic strategies to reduce LV filling pressures and to improve cardiac performance. In contrast, the therapy of patients presenting with decompensated heart failure in the setting of chronic LV systolic dysfunction, treated with angiotensin-converting enzyme inhibitors, digoxin, diuretics, and maybe beta blockers, represent a poorly defined clinical entity that lacks clear guidelines for treatment. These patients can present with symptoms of volume overload and/or low cardiac output without evidence for a volume overloaded state. Potential diagnostic and therapeutic approaches include (1) a pulmonary artery catheter for invasive hemodynamic monitoring, (2) intravenous inotropic therapy, (3) LV mechanical assist device therapy, and (4) cardiac transplantation. This review presents some of the advantages and disadvantages of each of these interventions for patients with chronic systolic dysfunction who present with decompensated symptoms and require specialized management in the hospital setting. [source] | |||||||||||||||||||