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NHS Greater Glasgow and Clyde
- Clinical Librarian -
NHSGGC Guidelines Newsletter
February 2007
Welcome to the NHS GG&C Guidelines Newsletter. The newsletter is intended as an information tool to help you
keep up to date with developments in your area of clinical expertise and interest. It is not in any way an
expression of organisational policy. The inclusion of a guideline in this newsletter does not imply that it is used, or
should be implemented, within NHS Greater Glasgow and Clyde. Any views expressed in guidelines quoted in
the newsletter will have to be subjected to the scrutiny of your own clinical judgement. You are, however,
welcome to use the guideline newsletter to inform your practice or service development.
This newsletter covers national and international guidelines that have either been published or added to specialist
databases (such as Medline or CINAHL) in the previous month. It is divided into three sections: one for clinical
guidelines from the UK, one for clinical guidelines from international bodies and one for publications on guideline
implementation. Within the two clinical sections, there are sub-categories to make it easier for you to find the
guidelines that might be relevant to your practice.
Where available, the newsletter includes abstracts and links to online full-text versions or executive summaries of
the guidelines.
Contents
A. UK Guidelines …………………………………………………………………………………………………….
p.2
Primary Care
………………………………………………………………………………………….
Cancer Care/Palliative Care
……………………………………………………………………………….
Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
………………………………………………………………………………………….
p. 2
p. 2
p. 3
p. 4
p. 4
p. 5
B. International Guidelines ………………………………………………………………………………………….
p. 6
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
Primary Care
………………………………………………………………………………………….
Cancer Care/Palliative Care
…………………………………………………………………….
Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
………………………………………………………………………………………….
C. Guidelines Implementation ……………………………………………………………………………………….
p. 6
p. 10
p. 11
p. 14
p. 14
p. 15
p. 16
If you would like to obtain full text versions of any of the guidelines listed in the newsletter, please refer to the
NHSScotland e-Library where you will find most of the guidelines in full text. The e-Library is accessible to all
NHSScotland staff at http://www.elib.scot.nhs.uk. Full text access requires an ATHENS password, which can be
obtained online from the e-Library website. For those guidelines that are not available online, please fill in and
sign the document request form that is included with the newsletter and send it to the Maria Henderson Library,
Gartnavel Royal Hospital. Phone: 0141-211 3913.
1
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
A. UK Guidelines
Primary Care
Cox NH, Eedy DJ, Morton CA. Guidelines for management of Bowen's disease: 2006 Update.
British Journal of Dermatology 156(1) 2007: 11-21.
This article represents a planned regular updating of the previous British Association of Dermatologists
(BAD) guidelines for management of Bowen's disease. They have been prepared for dermatologists on
behalf of the BAD. They present evidence-based guidance for treatment, with identification of the
strength of evidence available at the time of preparation of the guidelines.
National Institute for Cinical and Healthcare Excellence (NICE). Cinacalcet for the treatment of
secondary hyperparathyroidism in patients with end-stage renal disease on maintenance
dialysis therapy. London: NICE, 2007. URL: http://www.nice.org.uk/guidance/TA117 [last accessed:
06 January 2007].
Prodigy.
Polycystic
ovary
syndrome.
Newcastle:
Prodigy,
2007.
http://www.prodigy.nhs.uk/polycystic_ovary_syndrome [last accessed: 08 February 2007].
URL:
Scottish Intercollegiate Guidelines Network (SIGN). Acute coronary syndromes. Edinburgh: SIGN,
2007. URL: http://www.sign.ac.uk/pdf/sign93.pdf [last accessed: 08 February 2007].
Scottish Intercollegiate Guidelines Network (SIGN). Cardiac arrhythmias in coronary heart disease.
Edinburgh: SIGN, 2007. URL: http://www.sign.ac.uk/pdf/sign94.pdf [last accessed: 08 February 2007].
Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure.
Edinburgh: SIGN, 2007. URL: http://www.sign.ac.uk/pdf/sign95.pdf [last accessed: 08 February 2007].
Scottish Intercollegiate Guidelines Network (SIGN). Management of stable angina. Edinburgh: SIGN,
2007. URL: http://www.sign.ac.uk/pdf/sign96.pdf [last accessed: 08 February 2007].
Scottish Intercollegiate Guidelines Network (SIGN). Risk estimation and the prevention of
cardiovascular disease. Edinburgh: SIGN, 2007. URL: http://www.sign.ac.uk/pdf/sign97.pdf [last
accessed: 08 February 2007].
If you would like a copy of any SIGN Guidelines, please contact Grace Watson on 0141 211 3916 or email
[email protected].
Back to the Contents page
Cancer Care/Palliative Care
National Institute for Cinical and Healthcare Excellence (NICE). Bevacizumab and cetuximab for the
treatment
of
metastatic
colorectal
cancer.
London:
NICE,
2007.
URL:
http://www.nice.org.uk/guidance/TA118 [last accessed: 06 January 2007].
National Institute for Cinical and Healthcare Excellence (NICE). Gemcitabine for the treatment of
metastatic breast cancer. London: NICE, 2007. URL: http://www.nice.org.uk/guidance/TA116 [last
2
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
accessed: 06 January 2007].
Patkar V, Hurt C, Steele R, Love S, Purushotham A, Williams M, et al. Evidence-based guidelines
and decision support services: A discussion and evaluation in triple assessment of suspected
breast cancer. British Journal of Cancer 95(11) 2006: 1490-1496.
Widespread health service goals to improve consistency and safety in patient care have prompted
considerable investment in the development of evidence-based clinical guidelines. Computerised
decision support (CDS) systems have been proposed as a means to implement guidelines in practice.
This paper discusses the general concept in oncology and presents an evaluation of a CDS system to
support triple assessment (TA) in breast cancer care. Balanced-block crossover experiment and
questionnaire study. One stop clinic for symptomatic breast patients. Twenty-four practising breast
clinicians from United Kingdom National Health Service hospitals. A web-based CDS system. Clinicians
made significantly more deviations from guideline recommendations without decision support (60 out of
120 errors without CDS; 16 out of 120 errors with CDS, P<0.001). Ignoring minor deviations, 16
potentially critical errors arose in the no-decision-support arm of the trial compared with just one
(P=0.001) when decision support was available. Opinions of participating clinicians towards the CDS tool
became more positive after they had used it (P<0.025). The use of decision support capabilities in TA
may yield significant measurable benefits for quality and safety of patient care. This is an important
option for improving compliance with evidence-based practice guidelines. copyright 2006 Cancer
Research.
Back to the Contents page
Mental Health and Learning Disabilities
National Institute for Cinical and Healthcare Excellence (NICE). Methadone and buprenorphine for
managing opioid dependence. London: NICE, 2007. URL: http://www.nice.org.uk/guidance/TA114
[last accessed: 06 January 2007].
National Institute for Cinical and Healthcare Excellence (NICE). Naltrexone for the management of
opioid dependence. London: NICE, 2007. URL: http://www.nice.org.uk/guidance/TA115 [last
accessed: 06 January 2007]
Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, et al. Evidence-based guidelines for
management of attention-deficit/hyperactivity disorder in adolescents in transition to adult
services and in adults: Recommendations from the British Association for
Psychopharmacology. Journal of Psychopharmacology 21(1) 2007: 10-41.
Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a
large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's
services often with no readily identifiable adult service to support them, which presents problems as local
pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs).
In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry
services requesting assessment and treatment. For these reasons, the British Association for
Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of
evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this
initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion
derived from childhood evidence. We hope that, by the time these guidelines are updated, much
evidence will be available to address the many directions for future research that are detailed here.
Back to the Contents page
3
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
Dentistry
Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA, British Society of Paediatric Dentistry. Pulp
therapy for primary molars. International Journal of Paediatric Dentistry 1 2006: 15-23.
Back to the Contents page
Sexual Health, BBV and related Topics
Faculty of Family Planning & Reproductive Health Care Clinical Effectiveness Unit. First Prescription
of
Combined
Oral
Contraception.
London:
FFPRHC,
2007.
URL:
http://www.ffprhc.org.uk/admin/uploads/538_FirstPrescCombOralContJan06.pdf [last accessed: 08
February 2007].
Readers should note that the print version of this CEU Guidance Document (which was first published
and distributed to Faculty Members in July 2006) contained errors in Table 2 that the Clinical
Effectiveness Unit felt ought to be corrected in the website version. In addition, Faculty Members have
been sent a replacement copy of Table 2 containing the correct information for insertion in their printed
copy of the Guidance Document. The error concerned the inclusion of inaccurate information pertaining
to breast disease in UKMEC Category 2 (Benefits generally outweigh risks), which should instead have
been listed under UKMEC Category 3 (Risks generally outweigh benefits). In addition, further details on
hyperlipidaemias have been added to Table 2 for clarity. Note that this website version of the CEU
Guidance Document includes the correct version of Table 2.
Faculty of Family Planning & Reproductive Health Care Clinical Effectiveness Unit. Male and Female
Condoms.
London:
FFPRHC,
2007.
URL:
http://www.ffprhc.org.uk/admin/uploads/CEUguidanceMaleFemaleCondomsJan07.pdf [last accessed:
08 February 2007].
Lee CA, Chi C, Pavord SR, Bolton-Maggs PH, Pollard D, Hinchcliffe-Wood A, et al. The obstetric and
gynaecological management of women with inherited bleeding disorders--review with
guidelines produced by a taskforce of UK Haemophilia Centre Doctors' Organization.
Haemophilia 12(4) 2006: 301-36.
The gynaecological and obstetric management of women with inherited coagulation disorders requires
close collaboration between obstetrician/gynaecologists and haematologists. Ideally these women
should be managed in a joint disciplinary clinic where expertise and facilities are available to provide
comprehensive assessment of the bleeding disorder and a combined plan of management. The
haematologist should arrange and interpret laboratory tests and make provision for appropriate
replacement therapy. These guidelines have been provided for healthcare professionals for information
and guidance and it is also intended that they are readily available for women with bleeding disorders.
National Institute for Cinical and Healthcare Excellence (NICE). Heavy menstrual bleeding:
investigation and treatment. London: NICE, 2007. URL: http://www.nice.org.uk/guidance/CG44 [last
accessed: 06 January 2007].
Owusu-Ansah R, Gatongi D, Chien PFW. Health technology assessment of surgical therapies for
benign gynaecological disease. Best Practice & Research in Clinical Obstetrics & Gynaecology
20(6) 2006: 841-879.
This chapter summarises the evidence of the benefits and harm of surgical therapies for benign
gynaecological disease. We have limited the discussion in this chapter to three gynaecological
conditions - menorrhagia, endometriosis and benign ovarian tumours - with a further section on the
4
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
different surgical approaches for performing a hysterectomy for menorrhagia due to dysfunctional uterine
bleeding and pelvic masses such as fibroids and benign adnexal masses. The currently available
evidence suggests that there is little to choose between the four first-generation endometrial destruction
techniques - laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball
ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards
to the comparison of the different second-generation endometrial-destruction techniques but current
evidence suggests that bipolar radiofrequency ablation is more effective than thermal balloon ablation for
treating menorrhagia. Overall, the second-generation techniques are at least as effective as firstgeneration methods but are easier to perform and can be done under local rather than general
anaesthesia in some circumstances. Hysteroscopic endometrial ablation is an alternative to
hysterectomy and should be offered to women with menorrhagia because of its high satisfaction rates,
shorter operation time, shorter hospital stay, earlier recovery and reduced postoperative complications;
hysterectomy remains the surgical option of choice for women with intractable menorrhagia despite
repeated endometrial ablations and for those who do not wish under any circumstances to continue to
have menstrual bleeding. The combined use of laparoscopic laser ablation, adhesiolysis and uterine
nerve ablation has been shown to have a beneficial effect on pelvic pain associated with mild to
moderate endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal
and mild endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The
current available evidence suggests that the laparoscopic approach is superior to laparotomy for the
surgical management of benign ovarian cysts. It results in less postoperative pain and a shorter
postoperative hospital stay; it also costs less. With regards to the surgical approach for performing a
hysterectomy for menorrhagia and benign pelvic masses, vaginal hysterectomy should be performed
over laparoscopic and abdominal hysterectomy when possible. Where it is not possible to perform the
hysterectomy vaginally, then laparoscopic hysterectomy can be employed instead of abdominal
hysterectomy to avoid a laparotomy scar. There appears to be no significant advantage in performing a
subtotal hysterectomy instead of the total removal of the uterine corpus and cervix.
Winter AJ, Sulaiman Z, Hawkins D. BASHH Clinical Governance Committee guidance on the
appropriate use of HIV point of care tests. International Journal of STD & AIDS 17(12) 2006: 802805.
Back to the Contents page
Child Health
No relevant new guidance was published this month.
Back to the Contents page
5
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
B. International Guidelines
Primary Care
Allen UD, Aoki FY, Stiver HG. The use of antiviral drugs for influenza: Recommended guidelines
for practitioners. The Canadian Journal of Infectious Diseases & Medical Microbiology 17(5) 2006:
273-284.
The present document outlines current guidelines and supporting literature relating to the use of antiviral
drugs for chemoprophylaxis and influenza illness therapy in paediatric and adult settings. The focus is on
the management of influenza in interpandemic periods. Where appropriate, the areas in need of
additional research are identified. It will be necessary to update aspects of these guidelines as new
information emerges. The recommendations that follow represent the results of a joint effort supported
by the Canadian Paediatric Society and the Association of Medical Microbiology and Infectious Disease
Canada.
American Academy of Family Physicians (AAFP). Summary of recommendations for clinical
preventive
services.
Revision
6.2.
Leawood:
AAFP,
2006.
URL:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/clin_recs/cps.Par.0001.File.tmp/A
ugust2006CPS.pdf [last accessed: 08 February 2007].
Banks PA, Freeman ML, Practice Parameters Committee of the American College of
Gastroenterology. Practice guidelines in acute pancreatitis. American Journal of Gastroenterology
101(10) 2006: 2379-400.
Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition
recommendations and interventions for diabetes--2006: a position statement of the American
Diabetes Association. Diabetes Care 29(9) 2006: 2140-57.
Baos Vicente V, Barbero Gonzalez A, Diogene Fadini E, Eguilleor Villena A, Eyaralar Riera T, Iban~ez
Fernandez J, et al. Consensus document on the use of antibiotics in primary care.
Pharmaceutical Care Espana 8(2) 2006: 92-95.
Baran E, Szepietowski J, Maleszka R, Placek W, Adamski Z, Glinski W. Seborrheic dermatitis and
dandruff: Therapeutic consensus. Guidelines recommended by Polish Association of
Dermatologists. Dermatologia Kliniczna 8(4) 2006: 229-234.
Seborrheic dermatitis and dandruff are common skin disorders causing many therapeutic problems.
Here, we present the therapeutic guidelines for both conditions worked out by the group of experts on
behalf of Polish Association of Dermatologists. Ciclopirox olamine shampoo is recommended as
treatment of choice for seborrheic dermatitis located on the scalp and dandraff. Alternatively shampoos
containing ketoconazole and zinc pirythione could be used. Prophylaxis includes once weekly usage of
Ciclopirox olamine or ketoconazole shampoos. For seborrheic dermatitis in other locations combined
therapy with imidazoles and mild to moderate corticosteroids is recommended. Calcineurin inhibitors are
the best treatment option for face lesions. Alternatively monotherapy with antifungal agents or
corticosteroids or calcineurin inhibitors cold be tried. If there is a severe and/or recurrent course of the
disease systemic treatment with itraconazole or ketoconazole should be added. One can try also
terbinafine orally due to anti-inflammatory activity of this drug. Itraconazole 200 mg/day during the first
two days of each month is considered as an effective prophylaxis for severe seborrheic dermatitis.
Douketis J, Macie C, Cuddy K, Feightner J, MacMillan H, Elford W, et al. Non-surgical treatment of
obesity: Canadian Task Force on Preventive Health Care recommendation statement. Canadian
Family Physician 52(12) 2006: 1576-1578.
Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for
6
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
the management of herpes zoster. Clinical Infectious Diseases 44(SUPPL. 1) 2007: S1-S26.
The objective of this article is to provide evidence-based recommendations for the management of
patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality
of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing
guidelines, and the authors' clinical and research experience relevant to the management of patients
with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical
experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and
valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations
for the use of these medications are provided. In addition, suggestions are made for treatments that,
when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.
Golino P, Savonitto S, Fox K, Alonso Garcia MA, Ardissino D, Buszman P, et al. Guidelines on the
management of stable angina pectoris: Executive summary. Giornale Italiano di Cardiologia 7(8)
2006: 535-583.
Hening WA. Current Guidelines and Standards of Practice for Restless Legs Syndrome.
American Journal of Medicine 120(1 SUPPL. 1) 2007: S22-S27.
Algorithms for treatment of restless legs syndrome (RLS) include both nonpharmacologic and
pharmacologic therapy. Patients with RLS are divided into 3 groups: (1) those with intermittent RLS
symptoms; (2) those with daily RLS symptoms; and (3) those whose symptoms are refractory to
standard treatments. Many patients do not require medication, and symptoms often can be relieved with
good sleep hygiene and avoidance of medications and factors that provoke symptoms. Recent largescale clinical trials have proved the efficacy of therapy for RLS when it is required. Several classes of
medications are helpful, but dopaminergic therapy appears to be most effective and relieves symptoms
rapidly. The first step in managing RLS is to ensure that there is an adequate diagnosis; this involves
discriminating RLS from other conditions that may share a number of features. Finally, it is important to
tailor treatment to the needs of each individual patient. copyright 2007 Elsevier Inc. All rights reserved.
Institute for Clinical Systems Improvement (ICSI). Menopause and hormone therapy (HT):
collaborative decision-making and management. Bloomington: ICSI, 2006. URL:
http://www.icsi.org/menopause_and_hormone_therapy/menopause_and_hormone_replacement_ther
apy_ht___collaborative_decision_making_and_management_.html [last accessed: 08 February 2007].
Kaiser Permanente Care Management Institute. Secondary prevention of coronary artery disease
clinical practice guidelines. Oakland: Kaiser Permanente Care Management Institute, 2006. URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9532
[last accessed: 07
February 2007].
Messerli FH, Mancia G, Conti CR, Pepine CJ. Guidelines on the management of stable angina
pectoris: Executive summary: The Task Force on the Management of Stable Angina Pectoris of
the European Society of Cardiology. European Heart Journal 27(23) 2006: 2902-2903.
Miller PD. Guidelines for the diagnosis of osteoporosis: T-scores vs fractures. Reviews in
Endocrine & Metabolic Disorders 7(1-2) 2006: 75-89.
The development of bone mineral densitimometry methodologies, especially central dual energy X-ray
absorptiometry (DXA) methods have allowed this quantitative tool to be used to diagnose osteoporosis
before the first fragility fracture has occurred. The World Health Organization osteoporosis working group
set the stage for the BMD cut-off criteria development. The wide application of DXA has brought the
treatment of osteoporosis to the primary care level, a very necessary step if this increasingly prevalent
disease is to have a decline in its incidence. The most difficult osteoporosis cases, for which there are
many and their associated difficult DXA results and interpretation will always require specialists'
involvement. In particular, the embracement of the WHO absolute fracture risk validated project will take
DXA to a much greater level of value in making management decisions. In particular, the WHO absolute
risk data will allow physicians, health-economic policy makers, and payors of medical services to come
closer together to decide which patients are at a level of unacceptable fracture risk that justifies
treatment intervention. The implementation of this validated project will also remove the unacceptable
subjective computer printouts on DXA reports that often lead to the over-treatment of low risk patients
7
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
and at times the under-treatment of high risk patients. The evolution of the clinical interpretation of bone
densitometry has been a work in progress. Challenges in the clinical measurement of bone strength
remain and will also evolve. The field of osteoporosis has grown with the use of DXA and will continue to
embrace this technology as other technologies to measure fracture risk become applied in clinical
practice.
Naghavi M, Falk E, Hecht HS, Shah PK. The First SHAPE (Screening for Heart Attack Prevention
and Education) guideline. Critical Pathways in Cardiology: A Journal of Evidence Based Medicine
5(4) 2006: 187-190.
Atherosclerotic cardiovascular disease (A-CVD) is preventable. Major causal risk factors are known, and
effective and safe treatments exist. However, A-CVD remains the leading cause of death and severe
disability not only in affluent countries, but also globally. The burden of A-CVD is growing faster in poor
and developing countries threatening their future economic development. Traditional methods for
prevention of A-CVD have proven largely insufficient. Although many societal factors contribute to the
epidemic of A-CVD (eg, smoking, obesity, diabetes, insufficient physical activity, and so on) and deserve
renewed attention, early detection of the asymptomatic vulnerable patient who has significant subclinical
atherosclerosis presents as a low hanging fruit in primary prevention of A-CVD. The Screening for Heart
Attack Prevention and Education (SHAPE) Task Force, comprised of an international group of experts,
has proposed the First SHAPE Guideline to address a major shortcoming in the existing guidelines in
primary prevention of A-CVD. It is based on the observation that most heart attacks and strokes occur in
people who are not classified as high risk by the traditional risk factor-based approach recommended in
the United States (Framingham Risk Score) and Europe (SCORE). Unfortunately, these guidelines
provide inadequate warning to asymptomatic individuals with subclinical atherosclerosis who are
unaware of their high-risk status and are not aggressively treated by their physicians who follow the
existing recommendations. Consequently, most of these asymptomatic individuals, who are vulnerable to
a near-future heart attack, are not offered the benefit of existing prophylactic therapies. Unlike decades
ago when screening for risk factors of A-CVD was the only available risk stratification method in primary
prevention, today, noninvasive detection of atherosclerosis is feasible and widely available. It provides a
direct and individualized method for risk assessment. A large body of evidence has been compiled in
recent years showing the superior prognostic value of detecting atherosclerosis rather than risk factors of
atherosclerosis. The First SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45
to 75 years old and asymptomatic women 55 to 75 years old (except those defined as very low risk) to
detect and treat individuals with subclinical atherosclerosis. The intensity of treatment should correlate
with the severity of the disease. Among existing tools for detection of subclinical atherosclerosis, the
SHAPE Task Force has created the SHAPE Flow Chart based on the following 2 noninvasive imaging
techniques: coronary artery calcium scoring using computed tomography and carotid intima media
thickness and plaque using B-mode ultrasonography.
Nassef M, Shapiro G, Casale TB, Respiratory and Allergic Disease Foundation. Identifying and
managing rhinitis and its subtypes: allergic and nonallergic components--a consensus report
and materials from the Respiratory & Allergic Disease Foundation. Current Medical Research &
Opinion 22(12) 2006: 2541-8.
BACKGROUND: Rhinitis is one of the most common chronic disorders presenting to an internal
medicine, pediatric, or family practice clinician. It can greatly impact a patient's quality of life and exerts a
tremendous societal burden in terms of both its direct and indirect costs. In practice, in treatment
guidelines, and in the literature, discussions of rhinitis as an inflammatory (allergic) disease often eclipse
discussions of the nonallergic components, which often contribute to, or are responsible for, a patient's
disease. Recommendations for specific diagnostic criteria and treatment options for nonallergic rhinitis
are often lacking compared with those addressing allergic rhinitis. Previous guidelines primarily focus on
allergic rhinitis and do not provide easy-to-use tools to help primary care practitioners differentiate
between, and appropriately treat, the different types of rhinitis. Although it is often difficult and timeconsuming clinically to differentiate between the various rhinitis subtypes, this must be done in order to
select an appropriate treatment and achieve desirable outcomes. OBJECTIVE: We sought to develop a
useful diagnostic worksheet and treatment algorithm to help clinicians correctly identify rhinitis subtypes
and provide the appropriate therapy. METHODS: An expert multidisciplinary consensus panel,
comprising five allergy and immunology specialists and three ear, nose, and throat specialists with
expertise in the diagnosis and treatment of rhinitis, was assembled by the Respiratory & Allergic Disease
Foundation (RAD) to discuss a practical clinical approach to rhinitis that considers both inflammatory and
noninflammatory elements of the disease. During this meeting, the panel discussed current data and
treatment recommendations as well as clinical experiences and challenges in treating rhinitis. Materials
to help simplify the diagnosis and management of rhinitis were developed as tools to aid the healthcare
8
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
practitioner. RESULTS: A rhinitis diagnostic worksheet and treatment algorithm were developed by the
authors following the meeting, based on transcripts of the consensus panel's discussions. The diagnostic
worksheet can be used to quickly categorize patients as having allergic, nonallergic, or 'mixed' rhinitis
using descriptive criteria. Using the treatment algorithm as a guide, the appropriate treatment can then
be selected based on the suspected rhinitis subtype. CONCLUSION: The use of these clinical practice
tools may improve the management of rhinitis by helping clinicians to identify both the allergic and
nonallergic components of a patient's disease and choose an appropriate treatment. [References: 24]
Robson MC, Barbul A. Guidelines for the best care of chronic wounds. Wound Repair &
Regeneration 14(6) 2006: 647-648.
Robson MC, Cooper DM, Aslam R, Gould LJ, Harding KG, Margolis DJ, et al. Guidelines for the
treatment of venous ulcers. Wound Repair & Regeneration 14(6) 2006: 649-662.
Rome Foundation. Guidelines--Rome III Diagnostic Criteria for Functional Gastrointestinal
Disorders. Journal of Gastrointestinal & Liver Diseases 15(3) 2006: 307-12.
Singapore Ministry of Health. Diabetes mellitus. Singapore: Singapore Ministry of Health, 2006. URL:
http://www.moh.gov.sg/cmaweb/attachments/publication/36a449a907oh/Diabetes_Mellitus.Pdf
[last
accessed: 07 February 2007].
Steed DL, Attinger C, Colaizzi T, Crossland M, Franz M, Harkless L, et al. Guidelines for the
treatment of diabetic ulcers. Wound Repair & Regeneration 14(6) 2006: 680-692.
Sullivan WF, Heng J, Cameron D, Lunsky Y, Cheetham T, Hennen B, et al. Consensus guidelines
for primary health care of adults with developmental disabilities. Canadian Family Physician
52(11) 2006: 1410-1418.
OBJECTIVE: To develop practical Canadian guidelines for primary health care providers based on the
best available evidence for addressing health issues in adults with developmental disabilities (DD).
QUALITY OF EVIDENCE: Authors of background papers synthesized information from their own clinical
experience, from consultations with other experts, and from relevant professional publications. Based on
discussions of these papers at a colloquium of knowledgeable health care providers, a consensus
statement was developed. Standard criteria were used to select guidelines for consideration and to rank
evidence supporting them. Most evidence was level III. MAIN MESSAGE: People with DD have complex
health issues, some differing from those of the general population. Adequate primary health care is
necessary to identify these issues and to prevent morbidity and premature death. Physical, behavioural,
and mental health difficulties should be addressed, and primary health care providers should be
particularly attentive to the interactions of biological, psychological, and social factors contributing to
health, since these interactions can easily be overlooked in adults with DD. Attention must also be paid
to such ethical issues as informed consent and avoidance of harm. Developmental disabilities are not
grounds for care providers to withhold or to withdraw medically indicated interventions, and decisions
concerning such interventions should be based on patients' best interests. CONCLUSION: Implementing
the guidelines proposed here would improve the health of adults with DD and minimize disparities in
health and health care.
University of Michigan Health System. Heart failure - systolic dysfunction. Ann Arbor: University of
Michigan Health System, 2006. URL: http://cme.med.umich.edu/pdf/guideline/HeartFailure06.pdf [last
accessed: 07 February 2007].
University of Texas School of Nursing Family Nurse Practitioner Program. The efficacy of
antidepressants and various psychotherapies as adjunctive treatments for irritable bowel
syndrome.
Austin:
University
of
Texas,
School
of
Nursing,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9437
[last accessed: 08
February 2007].
University of Texas School of Nursing Family Nurse Practitioner Program. Screening for obstructive
sleep apnea in the primary care setting. Austin: University of Texas, School of Nursing, 2006. URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9436
[last accessed: 08
9
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
February 2007].
University of Texas School of Nursing Family Nurse Practitioner Program. Unintentional weight loss
in
the
elderly.
Austin:
University
of
Texas,
School
of
Nursing,
2006.
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9435
[last accessed: 08
February 2007].
University of Texas School of Nursing Family Nurse Practitioner Program. Diagnosis and
management of polycystic ovarian syndrome. Austin: University of Texas, School of Nursing,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9438
[last
accessed: 08 February 2007].
Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, et al. Guidelines for the treatment of
pressure ulcers. Wound Repair & Regeneration 14(6) 2006: 663-679.
Back to the Contents page
Cancer Care/Palliative Care
Abdo AA, Karim HA, Al Fuhaid T, Sanai FM, Kabbani M, Al Jumah A, et al. Saudi Gastroenterology
Association guidelines for the diagnosis and management of hepatocellular carcinoma:
summary of recommendations. Annals of Saudi Medicine 26(4) 2006: 261-5.
Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B, et al. Nutrition and
physical activity during and after cancer treatment: An American Cancer Society guide for
informed choices. CA: a Cancer Journal for Clinicians 56(6) 2006: 323-353.
Cancer survivors are often highly motivated to seek information about food choices, physical activity, and
dietary supplement use to improve their treatment outcomes, quality of life, and survival. To address
these concerns, the American Cancer Society (ACS) convened a group of experts in nutrition, physical
activity, and cancer to evaluate the scientific evidence and best clinical practices related to optimal
nutrition and physical activity after the diagnosis of cancer. This report summarizes their findings and is
intended to present health care providers with the best possible information from which to help cancer
survivors and their families make informed choices related to nutrition and physical activity. The report
discusses nutrition and physical activity issues during the phases of cancer treatment and recovery,
living after recovery from treatment, and living with advanced cancer; select nutrition and physical activity
issues such as body weight, food choices, and food safety; issues related to select cancer sites; and
common questions about diet, physical activity, and cancer survivorship.
Levy MH, Back A, Bazargan S, Benedetti C, Billings JA, Block S, et al. Palliative care. Clinical
practice guidelines in oncology. Journal of the National Comprehensive Cancer Network 4(8) 2006:
776-818.
Lopez M, Comandone A, Adamo V, Apice G, Bearzi I, Bracci R, et al. Clinical guidelines for the
management of gastrointestinal stromal tumors. Clinica Terapeutica 157(3) 2006: 283-299.
Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered
molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid
progress at molecular and clinical level observed in the last few years, there is a need to review the
current state of the art in order to delineate appropriate guidelines for the optimal management of these
tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology,
molecular biology and imaging, were invited to participate in a meeting to present and discuss a number
of pre-selected questions, and to achieve a consensus according to the categories of the National
Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the
French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the
NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117,
10
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT
and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with
negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an
experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in
unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent
disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib
can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib
therapy are not well known, but they should include reduction in tumor size and disease stabilization, as
well as reduction of tumor density on CT scan and metabolic activity on PET scan.
Morgan RJ, Jr., Alvarez RD, Armstrong DK, Chen LM, Copeland L, Fowler J, et al. Ovarian cancer.
Clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network
4(9) 2006: 912-39.
Rodgers GM. Guidelines for the use of erythropoietic growth factors in patients with
chemotherapy-induced anemia. Oncology 20(8 Suppl 6) 2006: 12-5.
The use of erythropoietic growth factors to treat chemotherapy-induced anemia (CIA) has been
increasing as clinicians become more aware of the ability of these drugs to improve the quality of life of
patients with cancer. The cost associated with erythropoietic growth factor therapy makes its appropriate
use a practical issue for physicians and hospitals. Clinical practice guidelines can benefit physicians by
increasing practice efficiency, reducing medical errors, increasing the quality of medical care, and
decreasing reimbursement problems. The American Society of Clinical Oncology and the American
Society of Hematology, the European Organisation for Research and Treatment of Cancer, and the
National Comprehensive Cancer Network (NCCN) have all published guidelines for using erythropoietic
growth factors to treat CIA, and this article reviews and summarizes those guidelines. Of the three
guidelines for the use of erythropoietic growth factors in CIA, the NCCN guidelines are based on the
most recent data. Current evidence indicates that erythropoietic growth factors can increase hemoglobin
levels, reduce the need for red blood cell transfusions, and improve quality of life; the effect of
erythropoietic therapy on outcomes in patients with CIA is still being investigated.
Wagman LD, Baird MF, Bennett CL, Bockenstedt PL, Cataland SR, Fanikos J, et al. Venous
thromboembolic disease. Clinical practice guidelines in oncology. Journal of the National
Comprehensive Cancer Network 4(9) 2006: 838-69.
Back to the Contents page
Mental Health and Learning Disabilities
Aarsland D, Emre M, Lees A, Poewe W, Ballard C. Practice Parameter: Evaluation and treatment
of depression, psychosis, and dementia in Parkinson disease (an evidence-based review):
Report of the Quality Standards Subcommittee of the American Academy of Neurology.
Neurology 68(1) 2007.
American Dietetic Association. Position of the American Dietetic Association: Nutrition
intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders.
Journal of the American Dietetic Association 106(12) 2006: 2073-82.
It is the position of the American Dietetic Association that nutrition intervention, including nutritional
counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients
with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment
across the continuum of care. Diagnostic criteria for eating disorders provide important guidelines for
identification and treatment. However, it is thought that a continuum of disordered eating may exist that
ranges from persistent dieting to subthreshold conditions and then to defined eating disorders, which
include anorexia nervosa, bulimia nervosa, and binge eating disorder. Understanding the complexities of
eating disorders, such as influencing factors, comorbid illness, medical and psychological complications,
and boundary issues, is critical in the effective treatment of eating disorders. The nature of eating
11
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
disorders requires a collaborative approach by an interdisciplinary team of psychological, nutritional, and
medical specialists. The RD is an integral member of the treatment team and is uniquely qualified to
provide medical nutrition therapy for the normalization of eating patterns and nutritional status. RDs
provide nutritional counseling, recognize clinical signs related to eating disorders, and assist with
medical monitoring while cognizant of psychotherapy and pharmacotherapy that are cornerstones of
eating disorder treatment. Specialized resources are available for RDs to advance their level of expertise
in the field of eating disorders. Further efforts with evidenced-based research must continue for improved
treatment outcomes related to eating disorders along with identification of effective primary and
secondary interventions.
Buchanan D, Tourigny-Rivard MF, Cappeliez P, Frank C, Janikowski P, Spanjevic L, et al. National
guidelines for seniors' mental health: The assessment and treatment of depression. Canadian
Journal of Geriatrics 9(SUPPL. 2) 2006: S52-S58.
The aim of this guideline is to improve the assessment, treatment, and management of depression in
older adults and to promote mental health through the provision of evidence-based recommendations.
The initial sections address issues related to screening and assessing for depression and outline the
various treatment approaches (i.e., psychotherapy and pharmacologic interventions) recommended,
depending on the type of depression and degree of severity. The treatment modalities for depression are
then presented in more detail, followed by recommendations for monitoring treatment. The final sections
address issues related to education, special populations, and systems of care for depression in older
adults.
Conn DK, Gibson M, Feldman S, Hirst S, Leung S, MacCourt P, et al. National guidelines for
seniors' mental health: The Assessment and Treatment of Mental Health Issues in Long-Term
Care Homes (focus on mood and behaviour symptoms). Canadian Journal of Geriatrics 9(SUPPL.
2) 2006: S59-S64.
Canadian Guidelines focusing on the Assessment and Treatment of Mental Health Issues in Long-Term
Care Homes were released in May 2006. This article provides a summary of the recommendations. The
prevalence of mental disorders in Long-Term Care Homes is high and there is limited availability of
psychiatric and other mental health services in most facilities. Much of the care is provided by primary
care physicians, personal support workers and a small number of registered nurses. The goal of these
Guidelines is to provide attending staff and consultants with a comprehensive approach to the care of
residents with mental illness. General care issues are highlighted, as optimal care can reduce the
incidence of behavioral symptoms. Organizational issues such as the development of the environment
as a therapeutic milieu and the need for staff training are also emphasized. Recommendations for the
screening and assessment of residents with behavioural or depressive symptoms are provided.
Management recommendations focus on appropriate investigations, a full array of non-pharmacological
interventions and the benefits versus risks of specific groups of psychotropic medications. The
Guidelines emphasize the need for ongoing monitoring and evaluation of therapeutic interventions, with
periodic tapering or discontinuation when the resident is stable.
Heisel MJ, Grek A, Moore SL, Jackson F, Vincent G, Malach FM, et al. National guidelines for
seniors' mental health: The assessment of suicide risk and prevention of suicide. Canadian
Journal of Geriatrics 9(SUPPL. 2) 2006: S65-S70.
The purpose of the Canadian Coalition for Seniors' Mental Health (CCSMH) practice guideline 'The
Assessment of Suicide Risk and Prevention of Suicide' is to provide clinical practice recommendations
for clinicians who encounter people 65 years of age and older who are at high risk for suicide because
they are thinking about it or are planning it or have recently tried to harm or kill themselves.
Hogan DB, Gage L, Bruto V, Burne D, Chan P, Wiens C, et al. National guidelines for seniors'
mental health: The assessment and treatment of delirium. Canadian Journal of Geriatrics
9(SUPPL. 2) 2006: S42-S51.
Delirium is a common, serious condition encountered in older persons that can have important long-term
consequences. The prevention, identification, assessment and management of delirium present
significant challenges to clinicians. For these guidelines a comprehensive literature review on the
assessment and management of delirium in older persons was conducted. This literature was used to
develop a series of evidence-based recommendations that the Delirium Guideline Development Group
12
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
ratified using a consensus process. In this paper, a summary of the recommendations directed at
practitioners and interdisciplinary care teams is provided. The Delirium Development Group believes that
the occurrence of delirium is not the inevitable complication of an acute illness in an older person. We
can modify its incidence and when it occurs we must provide competent, humane care.
Montgomery EB. Practice Parameter: Evaluation and treatment of depression, psychosis, and
dementia in Parkinson disease (an evidence-based review): Report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 68(1) 2007.
Montgomery Jr EB. Practice Parameter: Neuroprotective strategies and alternative therapies for
Parkinson disease (an evidence-based review) - Report of the Quality Standards Subcommittee
of the American Academy of Neurology. Neurology 68(2) 2007.
O'Leary KD, Woodin EM, Timmons Fritz PA. Can we prevent the hitting? Recommendations for
preventing intimate partner violence between young adults. Journal of Aggression, Maltreatment
& Trauma 13(3-4) 2006: 121-178.
All empirically-evaluated partner violence prevention programs were reviewed. Most changed knowledge
and attitudes regarding dating and sexual aggression, but few demonstrated behavioral change. Peer
violence and substance use programs directed toward at-risk individuals demonstrate much larger
effects than those directed at all individuals. Research is needed to (a) identify risk-factors for violence
persistence, (b) examine the cost-benefit of universal and targeted programs, and (c) explore the ability
of programs, such as parenting, stress management, and substance abuse programs, to reduce partner
aggression. We recommend that institutions implement hierarchical systems of prevention, with brief
interventions for all; more extensive program for moderate levels of aggression; and intensive
psychosocial and legal interventions for serious offenders.
Ossemann M, Bruls E, de Borchgrave V, De Cock C, Delcourt C, Delvaux V, et al. Guidelines for the
management of epilepsy in the elderly. Acta Neurologica Belgica 106(3) 2006: 111-6.
Seizures starting in patients over 60 years old are frequent. Diagnosis is sometimes difficult and
frequently under- or overrated. Cerebrovascular disorders are the main cause of a first seizure. Because
of more frequent comorbidities, physiologic changes, and a higher sensitivity to drugs, treatment has
some specificity in elderly people. The aim of this paper is to present the result of a consensus meeting
held in October 2004 by a Belgian French-speaking group of epileptologists and to propose guidelines
for the management and the treatment of epilepsy in elderly people.
Sullivan WF, Heng J, Cameron D, Lunsky Y, Cheetham T, Hennen B, et al. Consensus guidelines
for primary health care of adults with developmental disabilities. Canadian Family Physician
52(11) 2006: 1410-1418.
OBJECTIVE: To develop practical Canadian guidelines for primary health care providers based on the
best available evidence for addressing health issues in adults with developmental disabilities (DD).
QUALITY OF EVIDENCE: Authors of background papers synthesized information from their own clinical
experience, from consultations with other experts, and from relevant professional publications. Based on
discussions of these papers at a colloquium of knowledgeable health care providers, a consensus
statement was developed. Standard criteria were used to select guidelines for consideration and to rank
evidence supporting them. Most evidence was level III. MAIN MESSAGE: People with DD have complex
health issues, some differing from those of the general population. Adequate primary health care is
necessary to identify these issues and to prevent morbidity and premature death. Physical, behavioural,
and mental health difficulties should be addressed, and primary health care providers should be
particularly attentive to the interactions of biological, psychological, and social factors contributing to
health, since these interactions can easily be overlooked in adults with DD. Attention must also be paid
to such ethical issues as informed consent and avoidance of harm. Developmental disabilities are not
grounds for care providers to withhold or to withdraw medically indicated interventions, and decisions
concerning such interventions should be based on patients' best interests. CONCLUSION: Implementing
the guidelines proposed here would improve the health of adults with DD and minimize disparities in
health and health care.
Zhang B, El-Jawahri A, Prigerson HG. Update on bereavement research: evidence-based
13
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
guidelines for the diagnosis and treatment of complicated bereavement. J Palliat Med 9(5) 2006:
1188-203.
The past decade has witnessed considerable growth in the evidence-base from which clinical
recommendations for bereavement care can be made. Research now provides guidance to assist
clinicians in: a) recognizing differences between complicated and uncomplicated bereavement reactions,
b) identifying risk factors that may make certain individuals more vulnerable to bereavement-related
complications, c) appreciating and monitoring for potential adverse outcomes associated with
bereavement and d) taking actions to prevent or minimize maladjustment to the loss. In this article we
distinguish between the course of normal grief and abnormally prolonged, or complicated grief; clarify
distinctions between Complicated Grief Disorder and other mental disorders secondary to bereavement;
review outcomes associated with Complicated Grief Disorder; describe research on resilience in
bereavement; present findings on stigmatization and the use of mental health services among recently
bereaved persons; and summarize where the field is with respect to establishing the efficacy and
effectiveness of bereavement interventions. Promising new psychotherapies for Complicated Grief
Disorder have shown clinical efficacy. Nevertheless, further research is needed to enhance the detection
of vulnerable bereaved persons, to promote resilience following significant interpersonal loss, and to
tailor interventions to address the attachment issues that lie at the heart of this disorder.
Back to the Contents page
Dentistry
No relevant new guidance was published this month.
Back to the Contents page
Sexual Health, BBV and related Topics
Department of Veterans Affairs Hepatitis C Resource Center, Yee HS, Currie SL, Darling JM, Wright
TL. Management and treatment of hepatitis C viral infection: recommendations from the
Department of Veterans Affairs Hepatitis C Resource Center program and the National
Hepatitis C Program office. American Journal of Gastroenterology 101(10) 2006: 2360-78.
Chronic hepatitis C virus (HCV) infection affects approximately 1.3% of the general U.S. population and
5-10% of veterans who use Department of Veterans Affairs medical services. Chronic HCV is clearly
linked to the development of cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease
requiring liver transplantation. The consequences of HCV infection constitute a significant disease
burden and demonstrate the need for effective medical care. Treatment of chronic HCV is aimed at
slowing disease progression, preventing complications of cirrhosis, reducing the risk of HCC, and
treating extrahepatic complications of the virus. As part of a comprehensive approach to HCV
management, antiviral therapy with peginterferon alfa combined with ribavirin is the current standard of
care. Antiviral therapy should be provided to those individuals who meet criteria for treatment and who
are at greatest risk for progressive liver disease. Many of these patients may have comorbid medical and
psychiatric conditions, which may worsen while on antiviral therapy. Current antiviral regimens are
associated with significant adverse effects that can lead to noncompliance, dose reduction, and
treatment discontinuation. To overcome these barriers and to address these issues, it has become
crucial to facilitate a multidisciplinary team who can respond to and provide HCV-specific care and
treatment. Screening for HCV, preventing transmission, delaying disease progression, ensuring
appropriate antiviral therapy, and managing treatment-related adverse effects can improve patient
quality of life, treatment adherence, and ultimately, improve patient outcomes.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
guidelines on iatrogenic and self-induced infertility. International Journal of Gynaecology &
Obstetrics 94(2) 2006: 172-3.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
14
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
guidelines on obstetric fistula. International Journal of Gynaecology & Obstetrics 94(2) 2006: 174-5.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Safe
motherhood. International Journal of Gynaecology & Obstetrics 94(2) 2006: 167-8.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
guidelines on resuscitation of newborns. International Journal of Gynaecology & Obstetrics 94(2)
2006: 169-71.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, FIGO
Committee on Women's Sexual Reproductive Rights. Female genital cutting. International Journal of
Gynaecology & Obstetrics 94(2) 2006: 176-7.
Kaiser Permanente Southern California. Acute uterine bleeding unrelated to pregnancy.
Pasadena:
Kaiser
Permanente
Southern
California,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9671
[last accessed: 07
February 2007].
Yuen MF, Lai CL. Recommendations and potential future options in the treatment of hepatitis B.
Expert Opinion on Pharmacotherapy 7(16) 2006: 2225-31.
The natural history of chronic hepatitis B should be clearly defined before appropriate recommendations
for treatment can be advocated. In patients who acquire the disease in early life, the complications of
chronic hepatitis B continue to occur as a result of prolonged insidious damage to the liver, even in the
low viraemic phase. Treatment that ends with hepatitis B e antigen seroconversion with hepatitis B virus
DNA levels just below 10(5) copies/ml may not be sufficient. Patients with mild elevation of alanine
aminotransferase levels are already at considerable risk of developing complications. Treatment strategy
should aim at maximal and prolonged viral suppression to the lowest possible hepatitis B virus DNA
levels. Nucleotide/nucleoside analogues will become the mainstay of treatment. Future treatment
strategic plans should target maximising antiviral potency and minimising the chance of drug resistance.
[References: 55]
Back to the Contents page
Child Health
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for medical
management of first urinary tract infection in children 12 years of age or less. Cincinnati:
Cincinnati
Children's
Hospital
Medical
Center,
2006.
URL:
http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/ [last accessed: 07 February
2007].
Back to the Contents page
15
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
C. Guidelines Implementation
Barenkamp SJ. Implementing guidelines for the treatment of acute otitis media. Advances in
Pediatrics 53 2006: 241-54.
The recently published Clinical Practice Guideline for the Diagnosis and Management of Acute Otitis
Media represents a sincere effort by the AAP andthe AAFP to provide management guidelines for the
practitioner based upon the best scientific evidence available. Despite many years of research and
hundreds of clinical studies addressing various aspects of the epidemiology, clinical presentation, and
treatment of acute otitis media, important questions remain unaddressed or have been addressed in a
less than optimal fashion. These gaps in knowledge and deficiencies in several of the studies that
formed the scientific basis for the proposed guidelines are the major reasons behind continued
disagreement over certain recommendations. Until more comprehensive and careful analyses can be
performed, disagreements are likely to persist. Even so, there is general agreement about most of the
recommendations made in these guidelines, and these recommendations will provide a very valuable
framework for the practicing physician as he or she cares for children with acute otitis media. To briefly
review the major points, first is the critical importance of accurately diagnosing acute otitis media using a
combination of clinical findings and observable abnormalities of the tympanic membrane and middle ear
space. Particularly important is the differentiation of acute otitis media from otitis media with effusion.
Second is the value of treating the pain associated with acute otitis media as a regular component of
care, irrespective of any decision concerning antimicrobial treatment. Third is the option, for a select
group of older patients with nonsevere disease, of withholding antimicrobial therapy for the first 48 to 72
hours, if close follow-up and active parental involvement can be guaranteed. Fourth is the
recommendation that if an antimicrobial agent is used, high-dose amoxicillin (80 to 90 mg/kg/d) is the
treatment of choice for most children at the time of initial presentation unless disease is particularly
severe or the child has recently failed a previous course of the antibiotic. Finally highlighted is the
importance of ongoing education efforts on the part of physicians in advising parents about the things
they can do in their households to lessen the risk of future disease. [References: 82]
Simon J, Pilling S, Burbeck R, Goldberg D. Treatment options in moderate and severe depression:
Decision analysis supporting a clinical guideline. British Journal of Psychiatry 189(DEC) 2006:
494-501.
Background: Treatment options for depression include antidepressants, psychological therapy and a
combination of the two. Aims: To develop cost-effective clinical guidelines. Method: Systematic literature
reviews were used to identify clinical, utility and cost data. A decision analysis was then conducted to
compare the benefits and costs of antidepressants with combination therapy for moderate and severe
depression in secondary care in the UK. Results: Over the 15-month analysis period, combination
therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission
and no relapse compared with antidepressants. The cost per additional successfully treated patient was
4056 (95% CI 1400-18 300); the cost per quality-adjusted life year gained was 5777 (95% CI 1900-33
800) for severe depression and 14 540 (95% CI 4800-79 400) for moderate depression. Conclusions:
Combination therapy is likely to be a cost-effective first-line secondary care treatment for severe
depression. Its cost-effectiveness for moderate depression is more uncertain from current evidence.
Targeted combination therapy could improve resource utilisation.
Yang WW, Chiang IJ. EBCPG: A visualized evidence-based clinical practice guideline system.
Studies in Health Technology & Informatics 122 2006: 465-70.
Evidence-based clinical practice guidelines (CPG) have been recognized as an important guide to
physicians for decision-making. These guidelines can assist physicians in giving good clinical care to
their patients. Based on the overall healthcare improvements, medical care quality can be preserved
while practice discrepancies and errors can be eliminated. Clear representation and accessible guideline
content at the point care are also critical. One way to make implementation easier is through
computerized and visualized guidelines combined with evidence-based literature. Therefore, this paper
presents a computerized guideline system, EBCPG, which is composed of three main components:
CPGs exploration, EBM exploration and Web-base management to accommodate clinician decisionmaking and maintainability. Two tasks based on CPGs exploration and visualization technologies are
involved in facilitating the presentation of the CPG model. EBCPG provides a comprehensive way to
assist clinicians in making decisions according to the visualized clinical practice guidelines while dealing
with patients.
16
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].
Back to the Contents page
17
Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].