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NHS Greater Glasgow and Clyde
- Clinical Librarian -
NHSGGC Guidelines Newsletter
December 2006
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 …………………………………………………………………………………………………….
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Primary Care
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Cancer Care/Palliative Care
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Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
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B. International Guidelines ………………………………………………………………………………………….
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4.
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4.
5.
6.
Primary Care
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Cancer Care/Palliative Care
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Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
………………………………………………………………………………………….
C. Guidelines Implementation ……………………………………………………………………………………….
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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
Hay CR, Brown S, Collins PW, Keeling DM, Liesner R. The diagnosis and management of factor
VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors
Organisation. British Journal of Haematology 133(6) 2006: 591-605.
The revised UKHCDO factor (F) VIII/IX Inhibitor Guidelines (2000) are presented. A schema is proposed
for inhibitor surveillance, which varies according to the severity of the haemophilia and the treatment
type and regimen used. The methodological and pharmacokinetic approach to inhibitor surveillance in
congenital haemophilia has been updated. Factor VIII/IX genotyping of patients is recommended to
identify those at increased risk. All patients who develop an inhibitor should be considered for immune
tolerance induction (ITI). The decision to attempt ITI for FIX inhibitors must be carefully weighed against
the relatively high risk of reactions and the nephrotic syndrome and the relatively low response rate
observed in this group. The start of ITI should be deferred until the inhibitor has declined below 10
Bethesda Units/ml, where possible. ITI should continue, even in resistant patients, where it is well
tolerated and so long as there is a convincing downward trend in the inhibitor titre. The choice of
treatment for bleeding in inhibitor patients is dictated by the severity of the bleed, the current inhibitor
titre, the previous anamnestic response to FVIII/IX, the previous clinical response and the side-effect
profile of the agents available. We have reviewed novel dose-regimens and modes of administration of
FEIBA (factor VIII inhibitor bypassing activity) and recombinant activated FVII (rVIIa) and the extent to
which these agents may be used for prophylaxis and surgery. Bleeding in acquired haemophilia is
usually treated with FEIBA or rVIIa. Immunosuppressive therapy should be initiated at the time of
diagnosis with Prednisolone 1 mg/kg/d +/- cyclophosphamide. In the absence of a response to these
agents within 6 weeks, second-line therapy with Rituximab, Ciclosporin A, or other multiple-modality
regimens may be considered.
Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, et al. British Society for
Rheumatology and British Health Professionals in Rheumatology guideline for the
management of rheumatoid arthritis (the first two years). Rheumatology 45(9) 2006: 1167-1169.
Weston V, Coakley G, The British Society for Rheumatology Standards and Guidelines, Audit Working
Group, British Society for Antimicrobial Chemotherapy, British Orthopaedic Association, et al.
Guideline for the management of the hot swollen joint in adults with a particular focus on
septic arthritis. Journal of Antimicrobial Chemotherapy 58(3) 2006: 492-3.
The British Society for Rheumatology (BSR) Standards, Guidelines and Audit Working Group, in
conjunction with the British Society for Antimicrobial Chemotherapy, British Orthopaedic Association,
Royal College of General Practitioners and British Health Professionals in Rheumatology, has produced
an evidence-based guideline for the management of the hot swollen joint with particular focus on the
septic joint. The aim of the guideline is to help accurate diagnosis and appropriate treatment when a joint
is hot because of sepsis, while also ensuring that other causes such as crystal arthritis are recognized
and not over-treated.
Back to the Contents page
Cancer Care/Palliative Care
Milligan DW, Grimwade D, Cullis JO, Bond L, Swirsky D, Craddock C, et al. Guidelines on the
management of acute myeloid leukaemia in adults. British Journal of Haematology 135(4) 2006:
450-474.
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].
National Institute for Cinical and Healthcare Excellence (NICE). Hormonal therapies for the
adjuvant treatment of early oestrogen-receptor-positive breast cancer. London: NICE, 2006.
URL: http://www.nice.org.uk/guidance/TA112 [last accessed: 06.12.2006].
Back to the Contents page
Mental Health and Learning Disabilities
National Institute for Cinical and Healthcare Excellence (NICE). Dementia: Supporting people with
dementia and their carers in health and social care. London: NICE, 2006. URL:
http://www.nice.org.uk/guidance/cg42 [last accessed: 06.12.2006].
National Institute for Cinical and Healthcare Excellence (NICE). Donepezil, galantamine,
rivastigmine (review) and memantine for the treatment of Alzheimer's disease. London: NICE,
2006. URL: http://www.nice.org.uk/guidance/TA111 [last accessed: 06.12.2006].
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
Gazzard B, Bernard EJ, Boffito M, Churchill D, Edwards S, Fisher M, et al. British HIV Association
(BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2006).
HIV Medicine 7(8) 2006: 487-503.
Nandwani R, Clinical Effectiveness Group of the British Association for Sexual Health and HIV. 2006
United Kingdom national guideline on the sexual health of people with HIV: sexually
transmitted infections. International Journal of STD & AIDS 17(9) 2006: 594-606.
Rogstad KE, Palfreeman A, Rooney G, Hart GJ, Lowbury R, Mortimer P, et al. UK national
guidelines on HIV testing 2006. International Journal of STD & AIDS 17(10) 2006: 668-676.
Back to the Contents page
Child Health
Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. 2006. URL:
http://www.sign.ac.uk/pdf/sign91.pdf [last accessed: 06.12.2006].
If you have any comments on the above Guidelines, or 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
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].
B. International Guidelines
Primary Care
Anderson CAM, Miller IE. Dietary Recommendations for Obese Patients with Chronic Kidney
Disease. Advances in Chronic Kidney Disease 13(4) 2006: 394-402.
For optimal management of chronic kidney disease (CKD), dietary modification should be an integral
part of patient care. Dietary considerations for obese patients with CKD are numerous and complicated
and involve modification of intake of calories, protein, fat, phosphorus, and electrolytes. General
principles for dietary management of obese patients include (1) ensuring adequate monitoring of
nutritional status through assessment of diet, nutrition-related laboratory parameters, and
anthropometrics; (2) creation of an individualized diet plan that meets clinical guidelines and has
favorable effects on obesity-related conditions such as blood pressure and lipids; (3) careful attention to
patients' food choices, portion size, and food-preparation methods; (4) recommending adjustment of
overall energy intake to promote weight loss, yet maintain good nutritional status; and (5) modification of
diet as the patient's nutritional status changes and CKD progresses. The basic objectives of dietary
modification are to lighten the excretory load of products of metabolism and to help the kidney maintain
normal equilibrium of the body's internal environment. Dietary modifications must be individualized and
appropriate to the stage of CKD. This review describes dietary factors important in optimizing nutritional
status of obese patients with CKD. Additionally, current clinical practice guidelines and strategies for
meeting them are discussed.
Andros G, Armstrong DG, Attinger CE, Boulton AJM, Frykberg RG, Joseph WS, et al. Consensus
statement on negative pressure wound therapy (V.A.C. therapy) for the management of diabetic
foot wounds. Wounds: A Compendium of Clinical Research and Practice. (Supplement) 2006: 1-32.
In 2004, a multidisciplinary expert panel convened at the Tucson Expert Consensus Conference (TECC)
to determine appropriate use of negative pressure wound therapy as delivered by a Vacuum Assisted
Closure device (V.A.C.(R) Therapy, KCI, San Antonio, Tex) in the treatment of diabetic foot wounds.
These guidelines were updated by a second multidisciplinary expert panel at a consensus conference on
the use of V.A.C.(R) Therapy, held in February 2006, in Miami, Florida. This updated version of the
guidelines summarizes current clinical evidence, provides practical guidance, offers best practices to
clinicians treating diabetic foot wounds, and helps direct future research., The Miami consensus panel
discussed the following 12 key questions regarding V.A.C.(R) Therapy: 1) How long should V.A.C.(R)
Therapy be used in the treatment of a diabetic foot wound? 2) Should V.A.C.(R) Therapy be applied
without debriding the wound? 3) How should the patient using V.A.C.(R) Therapy be evaluated on an
outpatient basis? 4) When should V.A.C.(R) Therapy be applied following revascularization? 5) When
should V.A.C.(R) Therapy be applied after incision, drainage, and debridement of infection? 6) Should
V.A.C.(R) Therapy be applied over an active soft tissue infection? 7) How should V.A.C.(R) Therapy be
used in patients with osteomyelitis? 8) How should noncompliance to V.A.C.(R) Therapy be defined? 9)
How should V.A.C.(R) Therapy be used in combination with other modalities? 10) Should small,
superficial wounds be considered for V.A.C.(R) Therapy? 11) How should success in the use of
V.A.C.(R) Therapy be defined? 12) How can one combine effective offloading and V.A.C.(R) Therapy?
Anonymous. Guideline for semi-rush immunotherapy in wasp and bee allergy. Nederlands
Tijdschrift voor Dermatologie & Venereologie 16(7) 2006: 298-300.
Anonymous. Standard of the Dutch College of General Practitioners on urinary incontinence:
First revision. Huisarts en Wetenschap 49(10) 2006: 501-510.
Anonymous. Diabetes and coronary heart disease: New guidelines for treatment and prevention.
MMW Fortschritte der Medizin 148(41) 2006: 10-16.
Banks PA, Freeman ML, Fass R, Baroni DS, Mutlu EA, Bernstein DE, et al. Practice guidelines in
acute pancreatitis. American Journal of Gastroenterology 101(10) 2006: 2379-2400.
The diagnosis of acute pancreatitis requires two of the following three features: 1) characteristic
abdominal pain, 2) serum amylase and/or lipase >=3 times the upper limit of normal, and 3)
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].
characteristic findings of acute pancreatitis on CT scan. Risk factors of severity of acute pancreatitis at
admission include older age, obesity, and organ failure. Tests at admission that are also helpful in
distinguishing mild from severe acute pancreatitis include APACHE-II score >=8 and serum hematocrit
(a value <44 strongly suggests mild acute pancreatitis). An APACHE-II score that continues to increase
for the first 48 h strongly suggests the development of severe acute pancreatitis. A CRP >150 mg/L
within the first 72 h strongly correlates with the presence of pancreatic necrosis. The two most important
markers of severity in acute pancreatitis are organ failure (particularly multisystem organ failure) and
pancreatic necrosis. Contrast-enhanced CT scan is the best available test to distinguish interstitial from
necrotizing pancreatitis, particularly after 2-3 days of illness. Mortality of sustained multisystem organ
failure in association with necrotizing pancreatitis is generally >36%. Supportive care includes vigorous
fluid resuscitation that can be monitored in a variety of ways including a progressive decrease in serum
hematocrit at 12 and 24 h. Supplemental oxygen should be administered during the first 24-48 h,
bedside oxygen saturation monitored at frequent intervals, and blood gases obtained when clinically
indicated, particularly when oxygen saturation is <=95%. Transfer to an intensive care unit is
recommended if there is sustained organ failure or if there are other indications that the pancreatitis is
severe including oliguria, persistent tachycardia, and labored respiration. Patients who are unlikely to
resume oral nutrition within 5 days because of sustained organ failure or other indications require
nutritional support. Nutiritional support can be provided by TPN or by enteral feeding. There appear to be
some advantages to enteral feeding. Patients with acute pancreatitis caused by gallstones, who are
strongly suspected of harboring common bile duct stones on the basis of organ failure or other signs of
severe systemic toxicity (marked leukocytosis and/or fever), require evaluation for the presence of
choledocholithiasis, preferably within the first 24 h of admission. ERCP with endosocopic biliary
sphincterotomy and stone removal are indicated for patients with cholangitis, severe acute pancreatitis,
or high clinical suspicion or definitive demonstration of persistent bile duct stones by other imaging
techniques. Expectant management with interval cholecystectomy including intraoperative
cholangiogram is appropriate for most patients with mild to moderate pancreatitis and an improving
clinical course. Routine precholecystectomy ERCP is not recommended in patients with biliary
pancreatitis. In ambiguous cases, where available, evaluation for bile duct stones can beperformed by
endoscopic ultrasound or MRCP. The use of prophylactic antibiotics in necrotizing pancreatitis is not
recommended in view of a recent prospective randomized double-blind trial that showed no benefit and
in view of the concern that the prolonged use of potent antibiotic agents may lead to the emergence of
resistant Gram-positive organisms and fungal infections in the necrotic pancreas. It is reasonable to
administer appropriate antibiotics in necrotizing pancreatitis associated with fever, leukocytosis, and/or
organ failure while appropriate cultures (including culture of CT-guided percutaneous aspiration of the
pancreas) are obtained. Antibiotics should then be discontinued if no source of infection is found. CTguided percutaneous aspiration with Gram's stain and culture is recommended when infected pancreatic
necrosis is suspected. Treatment of choice of infected necrosis is surgical debridement. The timing of
surgery is left to the discretion of the pancreatic surgeon. Patients who are medically unfit for open
surgical debridement can be treated with less invasive surgical techniques, radiologic techniques, and, at
times, endoscopic techniques in medical centers with these capabilities. Treatment of sterile pancreatic
necrosis is generally medical during the first several weeks even in the presence of multisystem organ
failure. Eventually, after the acute inflammatory process has subsided and coalesced into an
encapsulated structure that is frequently called organized necrosis, debridement may be required for
intractable abdominal pain, intractable nausea or vomiting caused by extrinsic compression of stomach
or duodenum, or systemic toxicity (fever and/or intractable malaise). Debridement can be performed by
surgical, endoscopic, or radiologic techniques.
Berdel D, Buhl R, Dierkesmann R, Niebling W, Schultz K, Ukena D, et al. National Disease
Management Guideline for Asthma: Recommendations and evidence for 'asthma prevention'
issues. Zeitschrift fur Arztliche Fortbildung und Qualitatssicherung 100(6) 2006: 425-430.
The National Disease Management Program (NDM Program) represents the basic content of structured,
cross-sectoral Healthcare. In particular, the NDM Program is directed towards coordinating different
disciplines and areas of Healthcare. The recommendations are developed through interdisciplinary
consensus of the scientific medical societies on the basis of the best available evidence. Within this
scope the scientific medical societies concerned with the prevention, diagnosis, therapy and
rehabilitation of asthma consented upon a National Disease Management Guideline for Asthma in 2005.
Among other things, the following cornerstones of asthma prevention were agreed upon: Breastfeeding
and non-smoking were suggested as primary prevention measures for (expectant) parents. With respect
to secondary prevention, recommendations have been made for allergen avoidance, active/passive
smoking and immunotherapy. Regarding tertiary prevention, position statements on vaccination and
specific immunotherapy are developed. The present paper presents both the original texts of the
recommendations and the evidence underlying them.
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].
Bettoli V, Borghi A, Virgili A. Acne vulgaris: Guidelines for treatment. Rivista Italiana di Medicina
Dell'Adolescenza 4(2) 2006: 23-28.
Acne vulgaris is a common skin disease affecting about 70-90% of adolescents. It is a multifactorial
disease of the pilosebaceous units of the face, neck, chest and back, characterised by ductal
hyperkeratinization, androgen-mediated seborrhoea, Propionibacterium acnes colonization of the follicle
and inflammation. The features and the severity of acne are variable, depending on number, size and
predominant type of lesions (inflamed lesions, non-inflamed lesions, scars). Significant psychosocial
disabilities can arise from the disease. Frequently adolescents may experience poor self image, anxiety,
depression and social isolation. As a consequence, an effective management of the disorder can have a
considerable impact in patients with acne. The purpose of this paper is to help physicians in selecting an
appropriate treatment among the vast number of therapeutic options available according to acne clinical
presentation.
Billiard M, Bassetti C, Dauvilliers Y, Dolenc-Groselj L, Lammers GJ, Mayer G, et al. EFNS guidelines
on management of narcolepsy. European Journal of Neurology 13(10) 2006: 1035-48.
Management of narcolepsy with or without cataplexy relies on several classes of drugs, namely
stimulants for excessive daytime sleepiness and irresistible episodes of sleep, antidepressants for
cataplexy and hypnosedative drugs for disturbed nocturnal sleep. In addition, behavioral measures can
be of notable value. Guidelines on the management of narcolepsy have already been published.
However contemporary guidelines are necessary given the growing use of modafinil to treat excessive
daytime sleepiness in Europe within the last 5-10 years, and the decreasing need for amphetamines and
amphetamine-like stimulants; the extensive use of new antidepressants in the treatment of cataplexy,
apart from consistent randomized placebo-controlled clinical trials; and the present re-emergence of
gamma-hydroxybutyrate under the name sodium oxybate, as a treatment of all major symptoms of
narcolepsy. A task force composed of the leading specialists of narcolepsy in Europe has been
appointed. This task force conducted an extensive review of pharmacological and behavioral trials
available in the literature. All trials were analyzed according to their class evidence. Recommendations
concerning the treatment of each single symptom of narcolepsy as well as general recommendations
were made. Modafinil is the first-line pharmacological treatment of excessive daytime sleepiness and
irresistible episodes of sleep in association with behavioral measures. However, based on several large
randomized controlled trials showing the activity of sodium oxybate, not only on cataplexy but also on
excessive daytime sleepiness and irresistible episodes of sleep, there is a growing practice in the USA to
use it for the later indications. Given the availability of modafinil and methylphenidate, and the forseen
registration of sodium oxybate for narcolepsy (including excessive daytime sleepiness, cataplexy,
disturbed nocturnal sleep) in Europe, the place of other compounds will become fairly limited. Since its
recent registration cataplexy sodium oxybate has now become the first-line treatment of cataplexy.
Second-line treatments are antidepressants, either tricyclics or newer antidepressants, the later being
increasingly used these past years despite few or no randomized placebo-controlled clinical trials. As for
disturbed nocturnal sleep the best option is still hypnotics until sodium oxybate is registered for
narcolepsy. The treatments used for narcolepsy, either pharmacological or behavioral, are diverse.
However the quality of the published clinical evidences supporting them varies widely and studies
comparing the efficacy of different substances are lacking. Several treatments are used on an empirical
basis, specially antidepressants for cataplexy, due to the fact that these medications are already used
widely in depressed patients, leaving little motivation from the manufacturers to investigate efficacy in
relatively rare indications. Others, in particular the more recently developed substances, such as
modafinil or sodium oxybate, are evaluated in large randomized placebo-controlled trials. Our objective
was to reinforce the use of those drugs evaluated in randomized placebo-controlled trials and to reach a
consensus, as much as possible, on the use of other available medications.
Bornhoft G, Wolf U, Von Ammon K, Righetti M, Maxion-Bergemann S, Baumgartner S, et al.
Effectiveness, safety and cost-effectiveness of homeopathy in general practice - Summarized
health technology assessment. Forschende Komplementarmedizin 13(SUPPL. 2) 2006: 19-29.
Introduction: The Health Technology Assessment report on effectiveness, cost-effectiveness and
appropriateness of homeopathy was compiled on behalf of the Swiss Federal Office for Public Health
(BAG) within the framework of the 'Program of Evaluation of Complementary Medicine (PEK)'. Materials
and Methods: Databases accessible by Internet were systematically searched, complemented by
manual search and contacts with experts, and evaluated according to internal and external validity
criteria. Results: Many high-quality investigations of pre-clinical basic research proved homeopathic
high-potencies inducing regulative and specific changes in cells or living organisms. 20 of 22 systematic
reviews detected at least a trend in favor of homeopathy. In our estimation 5 studies yielded results
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].
indicating clear evidence for homeopathic therapy. The evaluation of 29 studies in the domain 'Upper
Respiratory Tract Infections/Allergic Reactions' showed a positive overall result in favor of homeopathy.
6 out of 7 controlled studies were at least equivalent to conventional medical interventions. 8 out of 16
placebo-controlled studies were significant in favor of homeopathy. Swiss regulations grant a high
degree of safety due to product and training requirements for homeopathic physicians. Applied properly,
classical homeopathy has few side-effects and the use of high-potencies is free of toxic effects. A
general health-economic statement about homeopathy cannot be made from the available data.
Conclusion: Taking internal and external validity criteria into account, effectiveness of homeopathy can
be supported by clinical evidence and professional and adequate application be regarded as safe.
Reliable statements of cost-effectiveness are not available at the moment. External and model validity
will have to be taken more strongly into consideration in future studies.
Dzieniszewski J, Jarosz M. Guidelines in the medical treatment of Helicobacter pylori infection.
Journal of Physiology & Pharmacology 57(SUPPL. 3) 2006: 143-154. URL:
Scientific evidence based on controlled clinical research confirm substantial benefits resulting from the
eradication of H. pylori infection in such pathologies of the alimentary tract as: gastric peptic and
duodenal ulcer (active or confirmed in the future and ulcer disease complications), MALT (Mucosa
Associated Limphoid Tissue) lymphoma, atrophic gastritis, past stomach resection, gastric cancer in the
family. The above group of indications is strongly recommended for eradicative treatment. During the last
several years there have been many guidelines made by international and national specialist groups.
'Test and treat' strategy of undiagnosed dyspepsia treatment is based on possibility to carry out noninvasive tests confirming H. pylori infection. First symptoms of dyspepsia in people over 45 years of age
constitute recommendation for endoscopy, as well as symptoms assumed to be 'alarming' (loss of
weight, anaemia, bloody vomiting, tarry stool, dysphagia) regardless of patient age. An individual
approach to eradication is proposed in gastroesophageal reflux disease, and use of non-steroid antiinflammatory drugs. Antibacterial activity towards H. pylori is shown by many antibiotics (amoxicillin,
macrolides, tetracyclines) and some other chemotherapeutic agents (nitroimidazoles) and bismuth. PPIs
are recommended, because through increase of pH in stomach they create conditions to act for
antibiotics. During the stage of first line triple therapy, it is advised to apply PPI and two antibacterial
medicines at the same time (PPI + amoxicillin+metronidazole or clarithromycin). Such therapeutic action
ensures achievement of eradication of H. pylori infection in 80-90% of cases. In case of lack of treatment
efficiency in the first-line therapy, 7-14 day treatment may be repeated using triple therapies (PPI + 2
antibiotics) substituting the antibiotic with the metronidazole or tetracycline, or quadruple therapies (PPI
+ bismuth citrate + 2 antibiotics). Side effects during eradicative treatments occur quite rarely (from 15 to
30%).
European Group on Graves Orbitopathy, Wiersinga WM, Perros P, Kahaly GJ, Mourits MP, Baldeschi
L, et al. Clinical assessment of patients with Graves' orbitopathy: the European Group on
Graves' Orbitopathy recommendations to generalists, specialists and clinical researchers.
European Journal of Endocrinology 155(3) 2006: 387-9.
Freeman AF, Shulman ST. Kawasaki disease: Summary of the American Heart Association
guidelines. American Family Physician 74(7) 2006: 1141-1150.
Kawasaki disease is an acute vasculitis of childhood that predominantly affects the coronary arteries.
The etiology of Kawasaki disease remains unknown, although an infectious agent is strongly suspected
based on clinical and epidemiologic features. A genetic predisposition is also likely, based on varying
incidences among ethnic groups, with higher rates in Asians. Symptoms include fever, conjunctival
injection, erythema of the lips and oral mucosa, rash, and cervical lymphadenopathy. Some children with
Kawasaki disease develop coronary artery aneurysms or ectasia, ischemic heart disease, and sudden
death. Kawasaki disease is the leading cause of acquired heart disease among children in developed
countries. This article provides a summary of the diagnostic and treatment guidelines published by the
American Heart Association.
Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic Foot
Disorders: A Clinical Practice Guideline (2006 Revision). Journal of Foot and Ankle Surgery 45(5
Supp) 2006: S2-S66.
The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and
worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese
people. An estimated 7% of the US population has diabetes, and because of the increased longevity of
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].
this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations,
infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and
lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons
with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot
complications can be prevented, dramatic reductions in frequency have been achieved by taking a
multidisciplinary approach to patient management. Using this concept, the authors present a clinical
practice guideline for diabetic foot disorders based on currently available evidence, committee
consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers,
infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not
dictate the care of all affected patients, they provide evidence-based guidance for general patterns of
practice. If these concepts are embraced and incorporated into patient management protocols, a major
reduction in diabetic limb amputations is certainly an attainable goal.
Hensler S, Hoidn S, Jork K. DEGAM practice guideline for stroke. ZFA. Zeitschrift fur
Allgemeinmedizin 82(9) 2006: 404-408.
Due to their high prevalence and high rate of mortality and subsequent disablement strokes and the
treatment thereof play an important role in general practice. The aim was to set up a guideline for high
quality treatment of stroke patients under the conditions of general practice. It follows the DEGAM 10step-procedure with special emphasis on evidence-based Medicine and practicability. During the first
(initial) phase the general practitioner's decisions are about immediate hospitalization or - if necessary emergency treatment. After inpatient treatment the task is to provide for home-based rehabilitation and
secondary prevention as follow-up. The major recommendations of the guideline are outlined hereafter.
copyright Georg Thieme Verlag KG Stuttgart.
Houston D, Lee D, Mant M. Hyperhomocysteinemia. Thrombosis Interest Group of Canada, 2006.
URL: http://www.tigc.org/eguidelines/hyperhomocysteinemia.htm [last accessed: 06.12.2006].
Hsieh ST. EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy.
European Journal of Neurology 13(12) 2006.
Kerr R, Johnson A, Rochester AP. Development of clinical guidelines for the use of electrical
stimulation in the management of urge urinary incontinence in women. Journal - Association of
Chartered Physiotherapists in Women's Health 99 2006: 49-57.
This paper describes the process of developing clinical guidelines for the physiotherapy management of
urge urinary incontinence using electrical stimulation. The work was undertaken as part of a Masterslevel module at the University of Bradford, Bradford, UK. The authors highlight the pitfalls encountered
and identify areas for further research. It has been ascertained from the literature that there is consistent
support for the effectiveness of electrical stimulation, with success and cure rates ranging between 37%
and 88%. A wide range of treatment parameters have been identified; however, there is a lack of
consensus for the selection of stimulation parameters and further good-quality research is required.
Kopp I, Lelgemann M, Ollenschlager G. The German disease management guideline asthma:
Methods and development process. Zeitschrift fur Arztliche Fortbildung und Qualitatssicherung
100(6) 2006: 411-418.
The German National Program for Disease Management Guidelines, which is being operated under the
auspices of the German Medical Association (GMA), the Association of the Scientific Medical Societies
(AWMF) and the National Association of Statutory Health Insurance Physicians (NASHIP), provides a
conceptual basis for the disease management of prioritized healthcare aspects. The main objective of
the program is to establish consensus of the medical professions on key recommendations covering all
sectors of healthcare provision and facilitating the coordination of care for the individual patient through
time and across interfaces. Within the scope of this program, the Scientific Medical Societies concerned
with the prevention, diagnosis, treatment and rehabilitation of asthma in children, adolescents and adults
have reached consensus on the core contents for a National Disease Management Guideline for
Asthma. This consensus was reached by applying formal techniques and on the basis of the adaptation
of recommendations from existing guidelines with high quality standards in methodology and reporting,
and information from evidence reports.
Lund JN, Nystrom PO, Coremans G, Herold A, Karaitianos I, Spyrou M, et al. An evidence-based
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].
treatment algorithm for anal fissure. Techniques in Coloproctology 10(3) 2006: 177-180.
Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many
centers follow guidelines based on local experience. In December 2005, we met with the aim of
developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and
secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary
care settings.
Mant M, Houston D, Vickars L. Hypercoagulable/Thrombophilic States. Thrombosis Interest Group
of Canada, 2006. URL: http://www.tigc.org/eguidelines/hypercoagstates.htm [last accessed:
06.12.2006].
Maury EE, Flores RH. Acute Monarthritis: Diagnosis and Management. Primary Care 33(3) 2006:
779-793.
The diagnosis for an acute monarthritis may still be elusive, even after an extensive initial evaluation. For
example, what should be done for a patient who has a paucity of extra-articular findings on physical
examination and an inflammatory synovial fluid with negative Gram's stain, cultures, and crystals?
Conservative management is always prudent. Assume the joint is infected and treat as such until proven
otherwise, because infection carries the highest morbidity and mortality of all the common acute
monarthopathies.
Maxion-Bergemann S, Bornhoft G, Sonderegger E, Renfer A, Matthiessen PF, Wolf U. Traditional
Chinese Medicine (phytotherapy): Health Technology Assessment report - Selected aspects.
Forschende Komplementarmedizin 13(SUPPL. 2) 2006: 30-41.
Objective: A summary of main aspects from a Health Technology Assessment report on Traditional
Chinese Medicine (TCM) in Switzerland concerning effectiveness and safety is given. Materials and
Methods: Literature search was performed through 13 databases, by scanning reference lists of articles
and by contacting experts. Assessed were quality of documentation, internal and external validity.
Results: Effectiveness: 43 articles concerning 'gastrointestinal tract and liver' were assessed. The
studies covering 7,436 patients were undertaken in China (35), Japan (3), USA (2) and Australia (3);
33/43 being controlled studies. 34/40 show significantly better results in the TCM-treated group. A
comparison of studies on results of treatment based on a diagnosis according to TCM criteria and
studies on results of treatment according to Western diagnosis shows that treatment based on TCM
diagnosis improves the result. The comparison of treatment by individual medication and standard
medication showed a trend in favor of individual medication. Safety: TCM training and practice for
physicians in Switzerland are officially regulated. Side effects occur, but no severe effects have been
registered up to now in Switzerland. TCM medicinals are imported; admission regulations are being
installed. Problems due to production abroad, Internet trade, self-medication or admixtures are possible.
Conclusion: The evaluation of the literature search provides evidence for a basic clinical effectiveness of
TCM therapy. Severe side effects were not observed in Switzerland. Regulations for trading and use of
medicinals prevent treatment risks. Further clinical studies in a Western context are required.
May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, et al. EFNS guidelines on the treatment of
cluster headache and other trigeminal-autonomic cephalalgias. European Journal of Neurology
13(10) 2006: 1066-77.
Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting
unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are
rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this
study was to give evidence-based recommendations for the treatment of these headache disorders
based on a literature search and consensus amongst a panel of experts. All available medical reference
systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT
syndrome. The findings in these studies were evaluated according to the recommendations of the
European Federation of Neurological Societies resulting in level A, B or C recommendations and good
practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at
least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of
cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose
depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly
effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent
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].
corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is
recommended. Methysergide, lithium and topiramate are recommended as alternative treatments.
Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal
hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of
SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with
topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute
therapy when patients are extremely distressed and disabled by frequent attacks.
McCarley P. The KDOQI clinical practice guidelines and clinical practice recommendations for
treating anemia in patients with chronic kidney disease: implications for nurses. Nephrology
Nursing Journal. 33(4) 2006: 423-6, 445, 427-8.
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative recently published revised
clinical practice guidelines and recommendations for the treatment of anemia. This article provides an
overview of the new guidelines and recommendations, with a focus on the hemoglobin treatment range,
iron status, use of erythropoiesis-stimulating agents, and adjuvant therapies.
Michigan Quality Improvement Consortium. Management and prevention of osteoporosis.
Southfield:
Michigan
Quality
Improvement
Consortium,
2006.
URL:
http://www.mqic.org/pdf/osteopor06.pdf [last accessed: 06.12.2006].
Michigan Quality Improvement Consortium. Adult preventive services (ages 50 - 65+). Southfield:
Michigan
Quality
Improvement
Consortium,
2006.
URL:
http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%205065+).pdf [last accessed: 06.12.2006].
Michigan Quality Improvement Consortium. Adult preventive services (ages 18 - 49). Southfield:
Michigan
Quality
Improvement
Consortium,
2006.
URL:
http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%201849).pdf [last accessed: 06.12.2006].
National Advisory Committee on Immunization (NACI). Varizig™ as the varicella zoster immune
globulin for the prevention of varicella In at-risk patients. Canada Communicable Disease Report
= Releve des Maladies Transmissibles au Canada 32(ACS-8) 2006. URL: http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/06vol32/acs-08/index.html [last accessed: 06.12.2006].
Reinhart K, Brunkhorst F, Bone H, Gerlach H, Grundling M, Kreymann G, et al. [Diagnosis and
therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German
Interdisciplinary Society for Intensive and Emergency Medicine]. Anaesthesist 1 2006: 43-56.
A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that
severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in
79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for
approximately 60,000 deaths and ranges as the third most frequent cause of death after acute
myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to
approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to
treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe
sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which
are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving
Sepsis Campaign (SSC) and take into account the structure and organization of the German health care
system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative
therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully
planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies
(AWMF).
Senese V, Hendricks MB, Morrison M, Harris J. SUNA clinical practice guidelines: male urethral
catheterization. Urologic Nursing. 26(4) 2006: 315.
Senese V, Hendricks MB, Morrison M, Harris J. SUNA clinical practice guidelines: female urethral
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].
catheterization. Urologic Nursing. 26(4) 2006: 314.
Skalidis EI, Vardas PE. Guidelines on the management of stable angina pectoris. European Heart
Journal 27(21) 2006.
Skerk V, Tambic-Andrasevic A, Andrasevic S, Kalenic S, Francetic I, Derezic D, et al. Guidelines for
antimicrobial treatment and prophylaxis of urinary tract infections - Year 2006. Infektoloski
Glasnik 26(2) 2006: 47-52.
Recommendations for antimicrobial treatment and prophylaxis of urinary tract infections (UTI) have been
made according to study results on the resistance of the most frequent causative agents of UTI to
antimicrobial drugs. The Committee for monitoring bacterial resistance to antibiotics in the Republic of
Croatia has been conducting this study since 1997. Uncomplicated cystitis is treated for 1, 3 or 7 days,
complicated cystitis for 7 days, pyelonephritis 10-14 days, and complicated UTI7 to 14 days, rarely
longer. For the treatment of cystitis the following drugs are used: fluoroquinolones, nitrofurantoin,
betalactam antibiotics, and in cases of lower resistance trimethoprim- sulfamethoxazole. A single therapy
with fluoroquinolones is administered to otherwise healthy young women with normal urinary tract in
whom cystitis symptoms have been present for less than 7 days. Empirical antimicrobial therapy of
pyelonephritis, recurrent and all complicated UTIs must be reviewed after urine culture finding is
obtained. In the treatment of bacterial prostatitis and febrile UTIs in males, the drug of first choice is
ciprofloxacin. Asymptomatic bacteriuria is treated in pregnant women, newborns, preschool children with
urinary tract abnormalities, before invasive urological and gynecological procedures, in kidney transplant
recipients, and in the first days of short-term urinary bladder catheterization. Antimicrobial prophylaxis is
administered primarily one hour prior to diagnostic or therapeutic invasive urological procedures, using
selected antimicrobial agents.
Tan D, Darmasetiawan S, Haines CJ, Huang KE, Jaisamram U, Limpaphayom KK, et al. Guidelines
for hormone replacement therapy of Asian women during the menopausal transition and
thereafter. Climacteric 9(2) 2006: 146-51.
These Guidelines summarize the position of an Expert Panel on Menopause in Asian Women regarding
the use of hormone replacement therapy (HRT) during the menopausal transition and thereafter. They
are intended to aid gynecologists, family physicians and other health-care professionals in providing
optimal care to menopausal Asian women who desire HRT.
Tupker RA, Dubois AEJ, De Groot H, Knulst AC, Lucker GPH. Guidelines for immunotherapy of
insect sensitivity. Nederlands Tijdschrift voor Dermatologie & Venereologie 16(7) 2006: 293-297.
Vignatelli L, Billiard M, Clarenbach P, Garcia-Borreguero D, Kaynak D, Liesiene V, et al. EFNS
guidelines on management of restless legs syndrome and periodic limb movement disorder in
sleep. European Journal of Neurology 13(10) 2006: 1049-65.
In 2003, the EFNS Task Force was set up for putting forth guidelines for the management of the
Restless Legs Syndrome (RLS) and the Periodic Limb Movement Disorder (PLMD). After determining
the objectives for management and the search strategy for primary and secondary RLS and for PLMD, a
review of the scientific literature up to 2004 was performed for the drug classes and interventions
employed
in
treatment
(drugs
acting
on
the
adrenoreceptor,
antiepileptic
drugs,
benzodiazepines/hypnotics, dopaminergic agents, opioids, other treatments). Previous guidelines were
consulted. All trials were analysed according to class of evidence, and recommendations formed
according to the 2004 EFNS criteria for rating. Dopaminergic agents came out as having the best
evidence for efficacy in primary RLS. Reported adverse events were usually mild and reversible;
augmentation was a feature with dopaminergic agents. No controlled trials were available for RLS in
children and for RLS during pregnancy. The following level A recommendations can be offered: for
primary RLS, cabergoline, gabapentin, pergolide, ropinirole, levodopa and rotigotine by transdermal
delivery (the latter two for short-term use) are effective in relieving the symptoms. Transdermal oestradiol
is ineffective for PLMD.
Wierman ME, Basson R, Davis SR, Khosla S, Miller KK, Rosner W, et al. Androgen therapy in
women: an Endocrine Society Clinical Practice guideline. Journal of Clinical Endocrinology &
Metabolism 91(10) 2006: 3697-710.
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].
OBJECTIVE: The objective was to provide guidelines for the therapeutic use of androgens in women.
PARTICIPANTS: The Task Force was composed of a chair, selected by the Clinical Guidelines
Subcommittee (CGS) of The Endocrine Society, six additional experts, a methodologist, and a medical
writer. The Task Force received no corporate funding or remuneration. EVIDENCE: The Task Force
used systematic reviews of available evidence to inform its key recommendations. The Task Force used
consistent language and graphical descriptions of both the strength of recommendation and the quality
of evidence, using the recommendations of the Grading of Recommendations, Assessment,
Development, and Evaluation (GRADE) group. The strength of a recommendation is indicated by the
number 1 (strong recommendation, associated with the phrase "we recommend") or 2 (weak
recommendation, associated with the phrase "we suggest"). The quality of the evidence is indicated by
cross-filled circles, such that [1 cross-filled circle, 3 empty circles] denotes very-low-quality evidence, [2
cross-filled circles, 2 empty circles] low quality, [3 cross-filled circles, 1 empty circle] moderate quality,
and [4 cross-filled circles] high quality. Each recommendation is followed by a description of the
evidence. CONSENSUS PROCESS: Consensus was guided by systematic reviews of evidence and
discussions during one group meeting, several conference calls, and e-mail communications. The drafts
prepared by the task force with the help of a medical writer were reviewed successively by The
Endocrine Society's CGS, Clinical Affairs Committee (CAC), and Executive Committee. The version
approved by the CGS and CAC was placed on The Endocrine Society's web site for comments by
members. At each stage of review, the Task Force received written comments and incorporated needed
changes. CONCLUSIONS: We recommend against making a diagnosis of androgen deficiency in
women at present because of the lack of a well-defined clinical syndrome and normative data on total or
free testosterone levels across the lifespan that can be used to define the disorder. Although there is
evidence for short-term efficacy of testosterone in selected populations, such as surgically menopausal
women, we recommend against the generalized use of testosterone by women because the indications
are inadequate and evidence of safety in long-term studies is lacking. A review of the data currently
available is presented, and areas of future research are outlined. To formulate clinical guidelines for use
of testosterone in women, additional information will be necessary. This includes defining conditions that,
when not treated with androgens, have adverse health consequences to women; defining clinical and
laboratory parameters that distinguish those with these conditions; and assessing the efficacy and longterm safety of androgen administration on outcomes that are important to women diagnosed with these
conditions. This necessary clinical research cannot occur until the biological, physiological, and
psychological underpinnings of the role of androgens in women and candidate disorders are further
elucidated.
Yehia H, Gerritsen A. Guidelines for the use of antithrombotics in elderly patients with atrial
fibrillation. Tijdschrift voor Verpleeghuisgeneeskunde 31(4) 2006: 114-118.
Atrial fibrillation is the most prevalent cardiac arrhythmia. It is an important independent risk factor for
thromboembolic stroke. Antithrombotic therapy with coumarin derivatives or antiplatelet drugs have been
shown to be effective in reducing the relative risk of stroke from atrial fibrillation. In general, we have
noticed a tendency among some physicians not to prescribe oral anticoagulants for the elderly,
especially when there is a history of frequent falls. Based upon the results of large trials and statistical
analyses, we recommend the use of oral anticoagulants for all patients with atrial fibrillation unless there
is a contraindication for the use of such drugs. There are some contraindications, however age or
predisposition to falls are not considered as a contraindication.
Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, et al. EULAR evidence based
recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing
Committee for International Clinical Studies Including Therapeutics (ESCISIT). Annals of the
Rheumatic Diseases 65(10) 2006: 1312-1324.
Objective: To develop evidence based recommendations for the management of gout. Methods: The
multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based
medicine expert representing 13 European countries. Key propositions on management were generated
using a Delphi consensus approach. Research evidence was searched systematically for each
proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and
incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according
to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual
analogue and ordinal scales. Results: 12 key propositions were generated after three Delphi rounds.
Propositions included both non-pharmacological and pharmacological treatments and addressed
symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The
importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol
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].
consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were
emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs
(NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and
injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or
radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to
2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol
desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES =
1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be
hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible.
For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with
gastroprotection if indicated) are recommended. Conclusions: 12 key recommendations for management
of gout were developed, using a combination of research based evidence and expert consensus. The
evidence was evaluated and the SOR provided for each proposition.
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, et al. ACC/AHA/ESC 2006
Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of
Sudden Cardiac Death: a report of the American College of Cardiology/American Heart
Association Task Force and the European Society of Cardiology Committee for Practice
Guidelines (writing committee to develop Guidelines for Management of Patients With
Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in
collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
Circulation 114(10) 2006: 5.
Back to the Contents page
Cancer Care/Palliative Care
Ettinger DS, Bepler G, Bueno R, Chang A, Chang JY, Chirieac LR, et al. Non-small cell lung cancer
clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network
4(6) 2006: 548-82.
Lardinois D, De Leyn P, Van Schil P, Porta RR, Waller D, Passlick B, et al. ESTS guidelines for
intraoperative lymph node staging in non-small cell lung cancer. European Journal of Cardio
Thoracic Surgery 30(5) 2006: 787-792.
The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node
staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for
definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic
evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peerreviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS
members contributing on line, were used to reach a consensus. Systematic nodal dissection is
recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is
acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen
section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal
nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and
sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation
includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are
done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases
or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled
trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence
to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and
improve pathologic staging, which will help decide on the best adjuvant therapy.
Morgan Jr RJ, 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: 912-939.
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].
Ovarian neoplasms consist of several histopathologic entities, and treatment depends on the specific
tumor type. Epithelial ovarian cancer comprises most malignant ovarian neoplasms; however, other
pathologic subtypes (such as less common ovarian histopathologies) must be considered. These
guidelines discuss epithelial ovarian cancer as well as less common ovarian histopathologies, including
germ cell neoplasms, mixed mullerian tumors of the ovary, and ovarian stromal tumors.
O'Brien SM, Keating MJ, Mocarski ES. Updated guidelines on the management of
cytomegalovirus reactivation on patients with chronic lymphocytic leukemia treated with
alemtuzumab. Clinical Lymphoma & Myeloma 7(2) 2006: 125-130.
The anti-CD52 monoclonal antibody alemtuzumab is highly active in the treatment of chronic lymphocytic
leukemia (CLL) in patients with previously treated, relapsed, and/or refractory CLL as well as in patients
with previously untreated disease. The general immunosuppressive impact and toxicities associated with
alemtuzumab therapy are largely predictable and manageable. In particular, cytomegalovirus (CMV)
reactivation is now a well-documented complication in patients receiving alemtuzumab. This article
discusses several strategies for monitoring and treating CMV reactivation in patients with CLL receiving
alemtuzumab-based therapy and provides practical recommendations for CMV management by building
upon the guidelines published previously in 2004.
Back to the Contents page
Mental Health and Learning Disabilities
Anonymous. Psychiatric evaluation of adults, second edition. American Journal of Psychiatry.
163(6) 2006: Supplement: 3-36.
Geyer D, Batra A, Beutel M, Funke W, Gorlich P, Gunthner A, et al. AWMF Guideline: Post-acute
treatment of alcohol abuse and dependence. Sucht: Zeitschrift fur Wissenschaft und Praxis 52(1)
2006: 8-34.
Aim: To produce 52 guidelines (according to AWMF, 2001) for the post-acute treatment of patients with
alcohol dependence. Methods: Systematic review of the literature, expert judgment and ultimate
consensual agreement. Results: Measures for long-term treatment and aftercare are proposed to
improve or re-establish the functioning and performance of chronically ill or disabled alcohol abusers in
everyday life and in the work environment. Addiction-specific therapies and general treatment
approaches (e. g. psychotherapy, occupational therapy) are recommended on the basis of evidencebased criteria (according to SIGN, 1999) and clinical judgments (according to APA, 1995) for an
integrated and sequential approach to the treatment of inpatients and outpatients. Conclusions: These
evidence-based guidelines can help physicians and practitioners in in-and out-patient settings to improve
their psycho-, socio-, and pharmaco-therapeutic competences.
Meierkord H, Boon P, Engelsen B, Gocke K, Shorvon S, Tinuper P, et al. EFNS guideline on the
management of status epilepticus. European Journal of Neurology 13(5) 2006: 445-450.
The objective of the current paper was to review the literature and discuss the degree of evidence for
various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE
for relevant literature from 1966 to January 2005. Furthermore, the Cochrane Central Register of
Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our
judgement of the relevance of the references to the subject. Recommendations were reached by
informative consensus approach. Where there was a lack of evidence but consensus was clear we have
stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive
status epilepticus (GCSE) is intravenous (i.v.) administration of 4 mg of lorazepam or 10 mg of diazepam
directly followed by 15-18 mg/kg of phenytoin or equivalent fosphenytoin. If seizures continue for more
than 10 min after first injection another 4 mg of lorazepam or 10 mg of diazepam is recommended.
Refractory GCSE is treated by anaesthetic doses of midazolam, propofol or barbiturates; the
anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h.
The initial therapy of non-convulsive SE depends on the type and the cause. In most cases of absence
SE, a small i.v. dose of lorazepam or diazepam will terminate the attack. Complex partial SE is initially
treated such as GCSE, however, when refractory further non-anaesthetising substances should be given
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].
instead of anaesthetics. In subtle SE i.v. anaesthesia is required.
Michigan Quality Improvement Consortium. Management of adults with major depression.
Southfield:
Michigan
Quality
Improvement
Consortium,
2006.
URL:
http://www.mqic.org/pdf/depres_g06.pdf [last accessed: 06.12.2006].
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: 111-116.
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.
Petitjean F. Therapeutic guidelines in schizophrenia. Encephale 32(5 III) 2006: S855-S857.
van Ruckevorsel K, Boon P, Hauman H, Legros B, Osseman M, Sadzot B, et al. Standards of care
for non-convulsive status epilepticus: Belgian consensus recommendations. Acta Neurologica
Belgica 106(3) 2006: 117-124.
Non-convulsive status epilepticus (NCSE) makes up around one-third of all cases of SE, affecting
approximately 1,000 to 4,000 individuals per year in Belgium. Compared with convulsive SE, NCSE has
received considerably less attention, is underdiagnosed and undertreated. However, if recognised,
NCSE can however be treated successfully. A workshop was convened by neurologists from major
Belgian centres to review the latest information on NCSE and to make recommendations on diagnosis
and treatment. These recommendations are not only intended for neurologists, but also for primary care
physicians and physicians in intensive care units. NCSE should be suspected whenever cases of
fluctuating consciousness or abrupt cognitive or behavioural changes are noted. Confirmation of
diagnosis by EEG should be obtained wherever possible. In view of the often subtle clinical signs, EEG
is also vital for monitoring treatment outcome. Non-comatose patients should generally be treated in a
neurology ward since referral to an ICU is unnecessary. First-line treatment should be an intravenous
benzodiazepine. For many patients who fail to respond to benzodiazepines, intravenous valproate will
successfully abrogate seizure activity. Intravenous phenytoin can be used in patients with focal NCSE in
whom valproate is contraindicated or ineffective. Time and care should be spent in identifying an
appropriate and effective antiepileptic drug regimen without recourse to anaesthesia. For comatose
patients, treatment intensity should be graded according to epilepsy history, general medical state and
prognosis. In some patients, intensive remedial measures may allow rapid resolution of NSCE, whereas
in more vulnerable patients, such treatment may be counterproductive.
Wynaden D, Landsborough I, McGowan S. Best practice guidelines for the administration of
intramuscular injections in the mental health setting. Int J Mental Health Nursing 15(3) 2006: 195200.
Back to the Contents page
Dentistry
American Dental Association Council on Scientific Affairs. Dental management of patients receiving
oral bisphosphonate therapy: expert panel recommendations. Journal of the American Dental
Association 137(8) 2006: 1144-50.
BACKGROUND: In light of the uncertainty surrounding the incidence of bisphosphonate-associated
osteonecrosis of the jaw (BON) and concomitant risk factors, dentists have questioned how to manage
the care of patients receiving oral bisphosphonate therapy. Expert panelists were selected by the
American Dental Association Council on Scientific Affairs on the basis of their expertise in the relevant
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].
subject matter and on their respective dental or medical specialties, and the panel was tasked with
developing guidance for dentists treating these patients. METHODS: There are no data from clinical
trials evaluating dental management of the care of patients receiving oral bisphosphonate therapy and,
therefore, these recommendations are based on a thorough review of the available literature relating to
bisphosphonate use and osteonecrosis of the jaw. After reviewing the literature, the panel developed
these recommendations based on their expert opinion. RESULTS: These panel recommendations focus
on conservative surgical procedures, proper sterile technique, appropriate use of oral disinfectants and
the principles of effective antibiotic therapy. CONCLUSIONS: The recommendations are a resource for
dentists to use in their practice, in addition to the dentist's own professional judgment, the information
available in the dental and medical literature, and information from the patient's treating physician. The
recommendations must be balanced with the practitioner's professional judgment and the individual
patient's preferences and needs.
American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride:
evidence-based clinical recommendations. Journal of the American Dental Association 137(8)
2006: 1151-9.
BACKGROUND: With the dramatic increase in the amount of scientific information available about oral
health, an evidence-based approach to oral health care and the practice of dentistry is necessary. There
is a need to summarize, critique and disseminate scientific evidence and to translate the evidence into a
practical format that is used easily by dentists The evidence-based clinical recommendations in this
report were developed by an expert panel established by the American Dental Association Council on
Scientific Affairs that evaluated the collective body of scientific evidence on the effectiveness of
professionally applied topical fluoride for caries prevention. The recommendations are intended to assist
dentists in clinical decision making. TYPES OF STUDIES REVIEWED: MEDLINE and the Cochrane
Library were searched for systematic reviews and clinical studies of professionally applied topical
fluoride--including gel, foam and varnish--through October 2005. RESULTS: Panelists were selected on
the basis of their expertise in the relevant subject matter. The recommendations are stratified by age
groups and caries risk and indicate that periodic fluoride treatments should be considered for both
children and adults who are at moderate or high risk of developing caries. Included in the clinical
recommendations is a summary table that can be used as a chairside resource. CLINICAL
IMPLICATIONS: The dentist, knowing the patient's health history and vulnerability to oral disease, is in
the best position to make treatment decisions in the interest of each patient. These clinical
recommendations must be balanced with the practitioner's professional expertise and the individual
patient's preferences.
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Sexual Health, BBV and related Topics
ACOG Committee on Gynecologic Practice. ACOG Committee Opinion: Number 345, October
2006: vulvodynia. Obstetrics & Gynecology 108(4) 2006: 1049-52.
Vulvodynia is a complex disorder that can be difficult to treat. It is described by most patients as burning,
stinging, irritation, or rawness. Many treatment options have been used, including vulvar care measures,
medication, biofeed training, physical therapy, dietary, modifications, sexual counseling, surgery. A
cotton swab test is used to distinguish generalized disease from localized disease. No one treatment is
effective for all patients. A number of measures can be taken to prevent irritation, and several
medications can be used to treat the condition.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical
Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum
hemorrhage. Obstetrics & Gynecology 108(4) 2006: 1039-47.
Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all
maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is
estimated that worldwide, 140,000 women die of postpartum hemorrhage each year-one every 4 minutes
(1). In addition to death, serious morbidity may follow postpartum hemorrhage. Sequelae include adult
respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan
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].
syndrome). Although many risk factors have been associated with postpartum hemorrhage, it often
occurs without warning. All obstetric units and practitioners must have the facilities, personnel, and
equipment in place to manage this emergency properly. Clinical drills to enhance the management of
maternal hemorrhage have been recommended by the Joint Commission on Accreditation of Healthcare
Organizations (2). The purpose of this bulletin is to review the etiology, evaluation, and management of
postpartum hemorrhage.
Anonymous. Guidelines for reducing the risk of viral transmission during fertility treatment.
Fertility & Sterility 86(5 SUPPL) 2006: S11-S17. URL:
These guidelines provide strategies, based on scientific principles and clinical experience, for reducing
the risk of virus transmission in couples seeking treatment for infertility.
Anonymous. Revised minimum standards for practices offering assisted reproductive
technologies. Fertility & Sterility 86(5 SUPPL) 2006: S53-S56.
Anonymous. Repetitive oocyte donation. Fertility & Sterility 86(5 SUPPL) 2006: S216-S217.
Anonymous. Use of clomiphene citrate in women. Fertility & Sterility 86(5 SUPPL) 2006: S187S193.
*CC is the best initial treatment for the majority of women whose infertility is associated with ovulatory
dysfunction (anovulation, luteal phase deficiency). Combined with appropriately timed IUI, CC treatment
also increases cycle fecundity in couples with unexplained infertility.*CC treatment generally should be
limited to the minimum effective dose and to no more than six ovulatory cycles. Failure to conceive after
successful CC-induced ovulation is indication for further evaluation to exclude other contributing causes
of infertility.*Combination therapies involving CC and other agents (metformin, glucocorticoids,
exogenous gonadotropins) may be effective when treatment with CC alone fails to induce ovulation.
Alternative strategies for the CC-resistant woman include treatment with aromatase inhibitors or
exogenous gonadotropins and, in selected patients, ovarian drilling.*CC treatment should be monitored
(BBT, serum P concentration, urinary LH excretion) to ensure its effectiveness in ovulation
induction.*Side effects of CC treatment are generally mild and well tolerated. The principal risk of CC
treatment is an increased incidence of multifetal gestation (<10%).
Anonymous. Correct coding for laboratory procedures during assisted reproductive technology
cycles. Fertility & Sterility 86(5 SUPPL) 2006: S168-S171.
New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with
assisted reproductive technologies. It is important for professionals in the field of assisted reproductive
technology (ART) to become familiar with them prior to their implementation. This document replaces the
July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for
Laboratory Procedures During Assisted Reproductive Technology.
Anonymous. Vaccination guidelines for female infertility patients. Fertility & Sterility 86(5 SUPPL)
2006: S28-S30.
Encounters for infertility care are opportunities to assess and update immunization status. Women of
reproductive age are often unaware of their need for immunization, their own immunization status, and
the potentially serious consequences of preventable disease on pregnancy outcome. The purpose of this
ASRM Practice Committee document is to summarize current recommendations regarding vaccinations
for women of reproductive age.
Anonymous. 2006 Guidelines for gamete and embryo donation. Fertility & Sterility 86(5 SUPPL)
2006: S38-S50.
The 2006 Guidelines for Gamete and Embryo Donation provide the latest recommendations for
evaluation of potential sperm, oocyte, and embryo donors, incorporating recent information about optimal
screening and testing for sexually transmitted infections, genetic diseases, and psychological
assessments. This revised American Society for Reproductive Medicine Practice Committee document
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].
incorporates recent information from the US Centers for Disease Control and Prevention, the US Food
and Drug Administration, and the American Association of Tissue Banks, with which all programs
offering gamete and embryo donation services must be thoroughly familiar.
Perinatal HIV Guidelines Working Group. Public Health Service Task Force recommendations for
use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and
interventions to reduce perinatal HIV-1 transmission in the United States. Rockville (MD): U.S.
Public
Health
Service,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9868
[last
accessed:
06.12.2006].
Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children.
Guidelines for the use of antiretroviral agents in pediatric HIV infection. Bethesda: U.S.
Department
of
Health
and
Human
Services,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9928
[last
accessed:
06.12.2006].
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: 2360-2378.
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.
Back to the Contents page
Child Health
Anonymous. The use of antiviral drugs for influenza: Recommended guidelines for
practitioners. Paediatrics & Child Health 11(8) 2006: 520-526.
Each year, there is a significant burden of illness due to influenza A viruses, and occasionally strains of
influenza B. While acknowledging the importance of immunization against influenza, it was thought
appropriate to develop contemporary guidelines on the use of antiviral drugs for chemoprophylaxis and
therapy of influenza illness, which are appropriate for the management of influenza in interpandemic
periods. The present article is an abbreviated version of a full statement outlining recommendations that
are the result of a joint effort supported by the Canadian Paediatric Society (CPS) and the Association of
Medical Microbiology and Infectious Disease (AMMI) Canada. The guidelines reflect the current state of
knowledge regarding the use of influenza antiviral drugs, and will be modified as additional research data
become available. Additional information on strategies to prevent influenza illness in the interpandemic
period may be obtained from the annual statement by the National Advisory Committee on
Immunization.
18
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].
Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology
Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children:
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology
and
Nutrition.
J
Pediatr
Gastroenterol
Nutr
43(3)
2006:
e1-13.
URL:
http://www.naspghan.org/PDF/PositionPapers/constipation.guideline.2006.pdf
[last
accessed:
06.12.2006].
Halperin SA. Recommendation for an adolescent dose of tetanus and diphtheria toxoids and
acellular pertussis vaccine: Reassurance for the future. Journal of Pediatrics 149(5) 2006: 589591.
Michigan Quality Improvement Consortium. Prevention and identification of childhood overweight.
Southfield:
Michigan
Quality
Improvement
Consortium,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9788
[last
accessed:
06.12.2006].
Michigan Quality Improvement Consortium. Management of persistent asthma in infants and
children 5 years of age and younger. Southfield: Michigan Quality Improvement Consortium, 2006.
URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9790 [last accessed:
06.12.2006].
Michigan Quality Improvement Consortium. Management of persistent asthma in children older
than 5 years of age. Southfield: Michigan Quality Improvement Consortium, 2006. URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9783
[last
accessed:
06.12.2006].
Back to the Contents page
19
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
Etxeberria Aguirre A, Rotaeche Del Campo R. Evidence-based clinical practice guidelines:
Current development and future perspectives. Revista de Calidad Asistencial 21(5) 2006: 228-237.
Because of interest in clinical practice guidelines (CPG) as instruments for improving clinical practice,
the production of these documents has markedly increased. In Spain, multiple documents described as
CPG are promoted by various institutions (health systems, scientific societies, industry, etc.). However,
recent evaluations of their quality reveal a wide margin for improvement in their design. CPG should be
developed through a systematic and structured process. The essence of a CPG is the formulation of
recommendations responding to a list of questions in which the management of a problem in a specific
context can be summarized. The response to the list of questions through evaluating and summarizing
the evidence constitutes the nucleus of the CPG and is what distinguishes it from other document types
that provide recommendations based mainly on 'expert' opinion. Recommendations should be graded
according to the quality of the evidence on which they are based. The highest level of evidence is
provided by systematic reviews and consequently consultation of these studies should be a priority.
There are several initiatives in Spain such as Guiasalud or Redeguias of the Red Tematica de
Investigacion MBE (Thematic Network for Research on EBM) that work on this type of CPG design. An
essential strategy is the coordination of parties interested in producing CPG (scientific societies, health
systems, etc.). Lastly, for CPG to improve the population's health, they must be disseminated and
systematically implemented.
Legare F, O'Connor AM, Graham ID, Saucier D, Cote L, Blais J, et al. Primary health care
professionals' views on barriers and facilitators to the implementation of the Ottawa Decision
Support Framework in practice. Patient Education & Counseling 63(3 SPEC. ISS) 2006: 380-390.
Objective: To describe primary health care professionals' views on barriers and facilitators for
implementing the Ottawa Decision Support Framework (ODSF) in their practice. Methods: Thirteen focus
groups with 118 primary health care professionals were performed. A taxonomy of barriers and
facilitators to implementing clinical practice guidelines was used to content-analyse the following
sources: reports from each workshop, field notes from the principal investigator and written materials
collected from the participants. Results: Applicability of the ODSF to the practice population, process
outcome expectation, asking patients about their preferred role in decision making, perception that the
ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most
frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of
evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were
identified only as barriers. Asking about values, health professional's outcome expectation, compatibility
with the patient-centered approach or the evidence-based approach, ease of understanding and
implementation, and ease of communicating the ODSF were identified only as facilitators. Conclusion:
These results provide insight on the type of interventions that could be developed in order to implement
the ODSF in academic primary care practice. Practice implications: Interventions to implement the ODSF
in primary care practice will need to address a broad range of factors at the levels of the health
professionals, the patients and the health care system.
Leslie LK, Stallone KA, Weckerly J, McDaniel AL, Monn A. Implementing ADHD Guidelines in
Primary Care: Does One Size Fit All? Journal of Health Care for the Poor and Underserved 17(2)
2006: 302-327. URL:
To determine if the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder (ADHD)
guidelines require tailoring for different settings, the researchers used a mixed-method research design
to review an ADHD quality improvement effort in community clinics and private offices in San Diego
County. Clinically, no differences were noted in rates of ADHD in the two settings. Children in community
clinics (58.3%) were more likely to report public insurance (p < .001), diverse ethnic backgrounds (p =
.003), low household incomes (p < .001), single parent households (p = .009), and to screen positive for
Oppositional Defiant Disorder/Conduct Disorder (p = .027). They were also more likely to have
experienced socio-environmental stressors (p < .001) including foster care, homelessness, parental drug
use, and domestic violence. No differences were noted by treatment received at 12 months postevaluation by office type. Open-ended interviews with clinicians confirmed these findings and revealed a
need for tailoring of implementation strategies to more closely fit the needs of children and families cared
for in public sector settings.
20
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].
Rosenfeld RM, Shiffman RN. Clinical Practice Guidelines: A Manual for Developing EvidenceBased Guidelines to Facilitate Performance Measurement and Quality Improvement.
Otolaryngology Head & Neck Surgery 135(4 SUPPL) 2006: S1-S28.
Rosenqvist M. Monitoring compliance to guidelines. Scandinavian Cardiovascular Journal 40(5)
2006: 260-261.
Sonnad SS, Matuszewski K. Control mechanisms for guideline implementation. Quality
Management in Health Care. 15(1) 2006: 15-26.
OBJECTIVES: One approach to reducing health care costs while ensuring high-quality patient care is
the use of medical practice guidelines. This study focuses on mechanisms that facilitate the
implementation of guidelines primarily intended to reduce cost without increasing patient risk, using a
multiinstitutional case study of a single guideline. SUBJECTS AND METHODS: We conducted
semistructured interviews with physicians and administrators involved with guideline implementation in
61 academic medical centers. The interviews included questions on both implementation methods and
the final success of implementation at each center. RESULTS: We identified 5 factors likely to be of
importance to the guideline implementation process: (1) the use of a written form to routinize the
process; (2) the acquisition of informed consent; (3) the presence of an active department chair (or
section chief) to serve as an opinion leader; (4) the use of individual-level monitoring; and (5) the
granting of financial incentives. CONCLUSIONS: This study allowed the identification of four processes
for guideline implementation. For hospitals contemplating implementation of guidelines aimed toward
cost reduction or selective use of various agents for other purposes, a decision process to identify the
control mechanism best suited to an individual institution is a crucial step toward success.
Tan WC, Ait-Khaled N. Dissemination and implementation of guidelines for the treatment of
asthma. International Journal of Tuberculosis & Lung Disease 10(7) 2006: 710-6.
Asthma remains a serious global health problem that affects people of all ages. Many asthma
management guidelines, both national and international, are available, but they are seldom
implemented. The implementation of guidelines remains a challenge worldwide, as barriers exist at
several levels. These barriers are generic, such as poverty, inadequate resources and poor
infrastructure, or specific, such as organisational, health care provider and patient factors. The barriers
are, however, potentially correctable, and the goal of guideline implementation is to translate evidencebased asthma management recommendations into real-life practice to improve patient health. This state
of the art article reviews the challenges and current status of and strategies for asthma dissemination
and implementation globally, and highlights the specific strategies for such improvement in developing
countries. [References: 53]
Weller K, Vetter-Kauzcok C, Kahler K, Hauschild A, Eigentler T, Pfohler C, et al. Guideline
implementation in Merkel cell carcinoma: An example of a rare disease. Deutsches Arzteblatt.
Ausg. A. 103(42) 2006: 2791-2796. URL:
Introduction: Little is known about the implementation of guidelines in rare diseases which, because of
low incidence, are often based on a low level of evidence. Merkel cell carcinoma is an agressive skin
malignancy which provides an example. Methods: A questionnaire survey relating to treatment of Merkel
call carcinoma between 1998 and 2004, the time since publication of the first version of the guidelines
was sent to 47 hospitals. Data were solicited on epidemiology, tumour grade and stage, treatment and
clinical course. Results: Replies were received for 150 patients. The analysis suggests that guideline
adherence is patchy. There were particularly strong variations in practice relating to adjuvant
radiotherapy. This is important because guideline conformity in this area is associated with fewer
recurrences. Discussion: The example of Merkel Cell carcinoma illustrates that the mere publication of
guidelines is insufficient to ensure that best evidence is put into practice.
Back to the Contents page
21
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].