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PubMed2007

[Prevention of brain infarction in patients with atrial fibrillation].

The patients with cardioembolic stroke sometimes suffer from severe neurological deficit and from recurrent strokes. Since atrial fibrillation, especially non-valvular atrial fibrillation (NVAF) is associated with over half of the cardioembolic strokes, the prevention of cardioembolic stroke in patients with NVAF is important. There have been some reports about how to prevent stroke. They have indicated that the best medication for preventing from stroke was anticoagulation by warfarin. Therefore, the guidelines recommended the patients with NVAF to take warfarin. In case with the older patients under 70 years, prothrombin international normalized ratio (PT-INR) should be kept from 2.0 to 3.0. On the other hand, if the patients with NVAF are over 70 years, PT-INR has to be controlled from 1.6 to 2.6. Before extraction of a tooth, anticoagulation should not be call off.

Age Factors↗

PubMed2001

Proof and policy from medical research evidence.

When judging the benefits and harms of health care and predicting patient prognosis, clinicians, researchers, and others must consider many types of evidence. Medical research evidence is part of the required knowledge base, and practitioners of evidence-based medicine must attempt to integrate the best available clinical evidence from systematic research with health professionals' expertise and patients' rights to be informed about diagnostic and therapeutic options available to them. Judging what constitutes sound evidence can be difficult because of, among other things, the sheer quantity, diversity, and complexity of medical evidence available today; the various scientific methods that have been advanced for assembling, evaluating, and interpreting such information; and the guides for applying medical research evidence to individual patients' situations. Recommendations based on sound research can then be brought forward as either guidelines or standards, and criteria exist by which valid guidelines and standards can be developed and promulgated. Nonetheless, gaps and deficiencies exist in current guidelines and in the methods for finding and synthesizing evidence. Interpreting and judging medical research involves subjective, not solely explicit, processes. Thus, developments in evidence-based medicine are an aid, but not a panacea, for definitively establishing benefits and harms of medical care, and the contributions that medical research evidence can make in any clinical or legal situation must be understood in a context in which judgment and values, understanding of probability, and tolerance for uncertainty all play a role.

Evidence-Based Medicine↗

PubMed2003

The national cholesterol education program adult treatment panel ill guidelines.

Coronary heart disease (CHD) remains the leading cause of death in the United States with more than 40% of all deaths each year directly attributed to the disease. Current evidence suggests that early identification and aggressive modification of risk factors offer the most promising approach to reducing the burden of CHD. Dyslipidemia has been identified as the primary risk factor leading to the development of CHD. It is estimated that nearly 65 million Americans require some form of lipid-modification therapy. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) set of guidelines released in May 2001 provides physicians with evidence-based recommendations on the classification, diagnosis, and treatment of lipid disorders. New features of the guidelines include a scoring system for calculating CHD risk, as well as the identification of CHD risk equivalents, lower treatment target goals, and an emphasis on conditions conferring a higher risk for CHD, such as the metabolic syndrome. The ATP III emphasis on risk assessment substantially increases the number of patients considered at risk for CHD and will expand the number eligible for lifestyle and drug interventions. This article highlights the new recommendations and reviews the impact of ATP III on osteopathic physicians.

Adult↗

PubMed2006

From vulnerable plaque to vulnerable patient--Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report.

Screening for early-stage asymptomatic cancers (eg, cancers of breast and colon) to prevent late-stage malignancies has been widely accepted. However, although atherosclerotic cardiovascular disease (eg, heart attack and stroke) accounts for more death and disability than all cancers combined, there are no national screening guidelines for asymptomatic (subclinical) atherosclerosis, and there is no government- or healthcare-sponsored reimbursement for atherosclerosis screening. Part I and Part II of this consensus statement elaborated on new discoveries in the field of atherosclerosis that led to the concept of the "vulnerable patient." These landmark discoveries, along with new diagnostic and therapeutic options, have set the stage for the next step: translation of this knowledge into a new practice of preventive cardiology. The identification and treatment of the vulnerable patient are the focuses of this consensus statement. In this report, the Screening for Heart Attack Prevention and Education (SHAPE) Task Force presents a new practice guideline for cardiovascular screening in the asymptomatic at-risk population. In summary, the SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45-75 years of age and asymptomatic women 55-75 years of age (except those defined as very low risk) to detect and treat those with subclinical atherosclerosis. A variety of screening tests are available, and the cost-effectiveness of their use in a comprehensive strategy must be validated. Some of these screening tests, such as measurement of coronary artery calcification by computed tomography scanning and carotid artery intima-media thickness and plaque by ultrasonography, have been available longer than others and are capable of providing direct evidence for the presence and extent of atherosclerosis. Both of these imaging methods provide prognostic information of proven value regarding the future risk of heart attack and stroke. Careful and responsible implementation of these tests as part of a comprehensive risk assessment and reduction approach is warranted and outlined by this report. Other tests for the detection of atherosclerosis and abnormal arterial structure and function, such as magnetic resonance imaging of the great arteries, studies of small and large artery stiffness, and assessment of systemic endothelial dysfunction, are emerging and must be further validated. The screening results (severity of subclinical arterial disease) combined with risk factor assessment are used for risk stratification to identify the vulnerable patient and initiate appropriate therapy. The higher the risk, the more vulnerable an individual is to a near-term adverse event. Because <10% of the population who test positive for atherosclerosis will experience a near-term event, additional risk stratification based on reliable markers of disease activity is needed and is expected to further focus the search for the vulnerable patient in the future. All individuals with asymptomatic atherosclerosis should be counseled and treated to prevent progression to overt clinical disease. The aggressiveness of the treatment should be proportional to the level of risk. Individuals with no evidence of subclinical disease may be reassured of the low risk of a future near-term event, yet encouraged to adhere to a healthy lifestyle and maintain appropriate risk factor levels. Early heart attack care education is urged for all individuals with a positive test for atherosclerosis. The SHAPE Task Force reinforces existing guidelines for the screening and treatment of risk factors in younger populations. Cardiovascular healthcare professionals and policymakers are urged to adopt the SHAPE proposal and its attendant cost-effectiveness as a new strategy to contain the epidemic of atherosclerotic cardiovascular disease and the rising cost of therapies associated with this epidemic.

Coronary Artery Disease↗

PubMed1999

The Scottish Leg Ulcer Project.

National and international guidelines on many topics have been introduced in recent years. It is unlikely that the implementation of few, or any, has been evaluated by randomized trial, nor have the impacts of guidelines when combined with training been evaluated. A national guideline produced by the Scottish Intercollegiate Guideline Network (SIGN) entitled 'Management of Chronic Leg Ulcer' was published in July 1998 and this may have influence on care and ultimately healing rates of leg ulcers. The purpose of this paper is to describe the design of a Scottish multi-centre trial and to present baseline data. The Scottish Leg Ulcer Project is a randomized controlled trial which commenced in July 1997 and is designed to compare the impact of the SIGN guideline with the impact of the SIGN guideline reinforced by a formal training programme, on healing rates of leg ulcers. Participants include 16 Scottish community healthcare trusts or health boards, with a population of approximately 2.7 million. Localities have been randomized into control (SIGN guidelines alone) and intervention (SIGN guideline plus a formal training programme). In the intervention localities, link nurses, after intensive training, cascaded similar training to all community staff involved in leg ulcer care. Data are provided by district nurse caseload managers in censuses every three months throughout a six-month baseline and 24-month trial period. The principal endpoint is an ulcer-free leg. The data collection is due to be completed in December 1999, and the project analysed and reported by June 2000.

Adult↗

PubMed2005

Best practice guidelines on informed consent for weight loss surgery patients.

OBJECTIVE: To provide evidence-based guidelines on informed consent and the education that underlies it for legally competent, severely obese weight loss surgery (WLS) patients. RESEARCH METHODS AND PROCEDURES: We conducted a systematic review of the scientific literature published on MEDLINE between 1984 and 2004. Three articles focused on informed consent for WLS; none was based on empirical studies. We summarized each paper and assigned evidence categories according to a grading system derived from established evidence-based models. We also relied on informed consent and educational materials from six WLS programs in Massachusetts. All evidence is Category D. Recommendations were based on a review of the available literature, informed consent materials from WLS programs, and expert opinion. RESULTS: This Task Group found that the informed consent process contributes to long-term outcome in multiple ways but is governed by limited legal requirements. We focused our report on the legal and ethical issues related to informed consent, i.e., disclosure vs. comprehension. Recommendations centered on the importance of assessing patient comprehension of informed consent materials, the content of those materials, and the use of active teaching/learning techniques to promote understanding. DISCUSSION: Although demonstrated comprehension is not a legal requirement for informed consent in Massachusetts or other states, the members of this Task Group found that the best interests of WLS patients, providers, and facilities are served when clinicians engage patients in active learning and collaborative decision making.

Digestive System Surgical Procedures↗

PubMedDate not supplied

Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing.

A systematic analysis of the research literature on skeletal pin site care was conducted, and the opinions of an expert panel were obtained. Four specific recommendations for skeletal pin site care are offered, with explicit discussions of the level of research support and/or expert panel support for each. Discussion of other pin site care issues is provided, and characteristics of the research base regarding skeletal pin site care are described.

Administration, Cutaneous↗

PubMed1999

Users' guides to the medical literature: XVI. How to use a treatment recommendation. Evidence-Based Medicine Working Group and the Cochrane Applicability Methods Working Group.

Clinicians can often find treatment recommendations in traditional narrative reviews and the discussion sections of original articles and meta-analyses. Making a treatment recommendation involves framing a question, identifying management options and outcomes, collecting and summarizing evidence, and applying value judgments or preferences to arrive at an optimal course of action. Each step in this process can be conducted systematically (thus protecting against bias) or unsystematically (leaving the process open to bias). Clinicians faced with a plethora of recommendations may wish to attend to those that are less likely to be biased. Therefore, we propose a hierarchy of rigor of recommendations to guide clinicians when judging the usefulness of particular recommendations. Recommendations with the highest rigor consider all relevant options and outcomes, include a comprehensive collection of the methodologically highest quality data with an explicit strategy for summarizing the data (that is, a systematic review), and make an explicit statement of the values or preferences involved in moving from evidence to action. High rigor recommendations come from systematically developed, evidence-based practice guidelines or rigorously conducted decision analyses. Systematic reviews, which typically do not consider all relevant options and outcomes or make the preferences underlying recommendations explicit, offer intermediate rigor recommendations. Traditional approaches in which the collection and assessment of evidence remains unsystematic, all relevant options and outcomes may not be considered, and values remain implicit, provide recommendations of weak rigor. In an era in which clinicians are barraged by recommendations as to how to manage their patients, this hierarchy provides a potentially useful set of guides.

Decision Making↗

PubMed2003

Evaluation of a brief low-cost intervention to improve antiretroviral treatment decisions.

An earlier pilot study found that US DHHS guidelines for antiretroviral treatment were not being successfully implemented (Mann et al., 2000). A brief and inexpensive intervention (visual aid checklist) was developed with the assistance of HIV-expert physicians in order to aid HIV/AIDS health care providers' and their patients' decisions about antiretroviral therapy. The visual aid checklist consisted of a two-page coloured diagram and explanation of key concepts (T-cell, viral load and resistance) and a checklist of the benefits and risks of antiretroviral therapy. Twenty adult HIV-positive subjects and eight health care providers were studied. Ten subjects were observed with their providers without the intervention being used, and then ten subjects were observed with the intervention. A pre-/post-test format was used to assess the patients' antiretroviral knowledge, patient-provider discussion of the DHHS guidelines, and provider satisfaction with the intervention. No differences in baseline HIV knowledge were found between the two groups. Results showed that patients in the intervention condition had greater knowledge of the benefits and risks of antiretroviral therapy than patients in the control condition. Providers reported that the intervention was useful in aiding and encouraging communication as well as conveying knowledge.

Adult↗

PubMed2000

[The systematic review is the foundation of evidence based medicine. One of the most important contributions to clinical medicine of the past decade].

The traditional narrative review has been shown repeatedly to be biased, mostly towards exaggerated treatment size effects. In contrast, the systematic review follows a strict protocol regarding focused questions, explicit criteria for literature searches, inclusion and exclusion criteria, critical appraisal and a synthesis which is quantitative when appropriate. There is empirical evidence that bias is reduced and that the conclusions reached have greater validity for the construction of treatment guidelines. In this paper three sources of systematic reviews are identified: the Cochrane Library, reviews published in peer-reviewed journals, and assessments of health technology (HTA-reports). Editors are encouraged to publish systematic reviews after proper critical appraisal, and readers are advised to search for such reviews when in need of guidance on important clinical questions.

Bias↗

PubMed2001

Investigating breast symptoms in primary care: enhancing concordance with current best advice.

The purpose of this study was to determine whether a targeted intervention could improve primary care practitioners' concordance with guidelines regarding management of women with breast symptoms. One hundred and twelve practitioners from randomly selected areas around Australia prospectively audited their investigations for each woman with a new breast symptom over two 12-week periods, before and five months after the release of national guidelines. Between the two audits, doctors received feedback on practice in relation to peers and attended one seminar in their local areas led by specialists from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons. For five recommendations, there were statistically significant improvements at the second audit in line with standard Investigation of a New Breast Symptom (INBS) guidelines. All these were for investigations of breast lumps. At first audit, there were seven recommendations where practitioners were already managing more than 80% of women in accordance with the INBS, and where there were no statistically significant increases in concordance at second audit. Another six recommendations had lower concordance with the recommendations prior to the release of the guidelines and did not significantly improve at second audit. These tended to be for less-common presentations and where clinical findings were not consistent with other test results. We concluded that a targeted intervention improved physician concordance with current best advice for investigating women who present with new breast symptoms in a primary care setting. Further educational programs are needed to improve investigations for rarer symptoms, and to enhance physicians' confidence in the results of their clinical examinations.

Adult↗

PubMed2000

Application of the National Cholesterol Education Program and joint European treatment criteria and clinical benefit in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS).

AIMS: The Air Force/Texas Coronary Atherosclerosis Prevention Study reported that diet with lovastatin, 20-40 mg daily, reduced the risk for a first coronary event by 37%. Because only 17% of this cohort would have qualified for drug therapy according to current U.S. guidelines, we assessed clinical benefit by risk categories. METHODS AND RESULTS: The main outcome measures were event rates of first acute major coronary events stratified by National Cholesterol Education Program and European criteria and target goal. Both those who would and would not be eligible for drug therapy, according to National Cholesterol Education Program guidelines, benefited from intervention. As expected, drug-eligible participants (event rate: lovastatin 1%/year, placebo 1.87%/year [relative risk 0.53, 95% confidence interval: 0.33, 0.84]) were at greater absolute risk for acute major coronary events than non-eligible participants (lovastatin 0.62%/year, placebo 0.93%/year [relative risk 0.67, 95% confidence interval: 0.51, 0.88]). Similar results were found using European guidelines for coronary risk management. Treatment to a target goal suggested a non-significant trend to greater benefit. CONCLUSIONS: The consistent relative benefit across risk categories suggests that it may be possible to improve identification of at-risk persons who would benefit from primary prevention, and to recommend appropriate goals of such treatment.

Aged↗

PubMed1999

Educational guidelines for achieving tight control and minimizing complications of type 1 diabetes.

Tight glucose control with intensive therapy in patients with type 1 diabetes (formerly known as juvenile-onset or insulin-dependent diabetes) can delay the onset and slow the progression of retinopathy, nephropathy and neuropathy. Optimal blood glucose control is defined by a target glycosylated hemoglobin level of less than 7 percent, a preprandial glucose level of 80 to 120 mg per dL (4.4 to 6.7 mmol per L) and a bedtime glucose level of 100 to 140 mg per dL (5.6 to 7.8 mmol per L). This article provides guidelines to help family physicians teach patients with type 1 diabetes how to achieve tight glucose control to help minimize complications. Guidelines include maintaining blood glucose levels at near normal by taking doses of short-acting insulin throughout the day supplemented by a nighttime dose of intermediate-acting insulin, monitoring blood glucose levels frequently, following a prudent diet, exercising regularly and effectively managing hypoglycemia, as well as empowering patients to lead their control efforts and rigorously controlling other risk factors for cardiovascular disease. Support from physicians, family members and friends is crucial to the success of a regimen of tight glucose control.

Blood Glucose↗

PubMed2006

A multicentre approach for the management of adults with congenital heart disease.

OBJECTIVE: At present, the level of care for adult congenital heart disease is not completely satisfactory in many European countries including Italy. The aim of this multicentre study was to evaluate the possibility of creating an active connection among different centres involved in the care of this patient population. METHODS: This study lasted two years, from December 2002 to December 2004. It involved six clinical centres located in the north, centre and south of Italy; a research centre (ISBEM) affiliated to the National Research Centre was also involved. Each centre was supposed to contribute with written information (about their specific subject) on the web site; our target readers were physicians, nurses and patients. The intranet part of the web connection was used for a registry to be filled with very simple information (demographic data, main diagnosis, reason for hospitalisation, type of treatment) about patients hospitalised after January 2000. The aim of the registry was to get a snapshot of the composition of the treated population, and the spectrum of the lesions. RESULTS: The main results are the following: (i) the creation of the web site www.guch-italia.it which can be accessed without a specific password; (ii) the creation of a registry in which we entered the clinical information of 1,231 patients; (iii) the presentation of guidelines on the web site, extrapolated from the recommendations for the management of adults with congenital heart disease from the Canadian Cardiovascular Society Consensus Conference. CONCLUSIONS: With this study we tried to create a national network of centres that have as an objective to optimise the assistance to patients with adult congenital heart disease, trying to make the approach as much homogeneous as possible.

Adolescent↗

PubMed1999

Ostomy care: foundation for teaching and practice.

Current approaches to ostomy management evolved from the extensive experience of surgeons, enterostomal therapy nurses, staff nurses, patients, and manufacturers. Advances in surgical techniques in the 1950's led to decreased morbidity and mortality previously associated with ostomy surgery. With these advances, a corresponding demand emerged to meet the rehabilitative needs of these patients by providing significant physical and psychological support. The birth of enterostomal therapy in 1958 focused interest, energy, and resources on this important area of patient care. Today's tradition-based practice continues to go a long way in meeting the physical and psychological needs of individuals undergoing ostomy surgery. However, in this era of managed care, shrinking healthcare dollars, and standardized guidelines, care practices not derived from evidence or consensus may jeopardize a patient's access to appropriate interventions and supplies. An exhaustive review of the literature revealed a paucity of ostomy-related research. The effectiveness of preoperative stoma site selection, prevention, care, and treatment of peristomal skin problems; and pouch selection and wearing times revealed a wealth of empirical evidence, but little or no objective data supporting commonly accepted interventions. The care of individuals with urinary and fecal diversions is both an art and a science. Evidence-based practice is needed to provide a firm foundation from which the art of individualized patient care can flourish. Research related to pre- and postoperative care and rehabilitation of individuals with ostomies can only serve to improve education, continuity of care, reimbursement, and most importantly, optimize patient care.

Education, Nursing, Continuing↗

PubMed2005

[COPD in the year 2005].

COPD is a widespread illness with an increasing prevalence and mortality rate. Current knowledge of its pathophysiology has it that COPD is not simply limited to the lungs, but must be understood as a systemic inflammatory reaction. The ATS/ERS guideline goes beyond the recommendations of the GOLD guideline, and takes account of the peculiarities of the European and North American healthcare systems (www.ersnet.org). In this context, the role of inhaled steroids, which is currently still under lively discussion, has to be revisited. Additional possible approaches include the administration of appetite stimulants and dietary measures, and the application of iron or erythropoietin. The TORCH study--currently the largest ongoing COPD study--is investigating the influence of inhaled glucocorticoids and long-acting beta2 agonists on mortality.

Administration, Inhalation↗

PubMed1996

Developing treatment guidelines for Alzheimer's disease and other dementias.

Developing treatment guidelines for Alzheimer's disease and other dementias depends primarily on a literature review. A recent review suggests that tacrine is modestly effective in treating cognitive symptoms and that-neuroleptic drugs are modestly effective in treating agitation and aggression. Few randomized, double-blind, placebo-controlled trials of other agents used for the treatment of cognitive and noncognitive symptoms of dementia have been performed. A variety of behavioral/environmental interventions show modest but nonspecific effects in treating Alzheimer's disease and other types of dementia. Family-focused support interventions are moderately effective and may delay nursing home placement.

Alzheimer Disease↗

PubMedDate not supplied

Acute exacerbation of COPD: nursing application of evidence-based guidelines.

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

Acute Disease↗