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PubMedDate not supplied

Guidelines for behavior management of The American Academy of Pediatric Dentistry.

(1) Behavior management is only in part a science and must be recognized as an art form to health care delivery. (2) The goals of behavior management are to achieve good dental health in the child patient and to help develop the child's positive attitude toward dental health. (3) The objectives of behavior management are to establish communication and to foster education, thereby alleviating fear and anxiety and building a trusting relationship between dentist and child. (4) All decisions regarding behavior must be based on a benefit versus risk evaluation. (5) Parents share in the decision-making process regarding treatment of their children.

Behavior Therapy↗

PubMed1999

[Good clinical practice in nutritional management of head and neck cancer patients].

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVE: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommandations for the nutritional management of the head and neck cancer patients. METHODS: Data have been identified by literature search using Medline and the expert groups personal reference lists. Once the guidelines were defined, the document was submitted for review to 121 independent reviewers, and to the medical committees of the 20 French Cancer Centres. RESULTS: The main recommendations for the nutritional management of head and neck cancer patients are that: 1) Nutritional management prevents undernutrition, improves quality of life, reduces adverse effects of the treatment and prevents treatment delay; 2) The nutritional management of the head and neck cancer patient must be done before, during and after cancer treatment; 3) Before treatment, the weight of the patient must be assessed: 10% of weight loss in 6 months requires to an urgent nutritional intervention; 4) During radiation therapy, feeding should be adapted to various characteristics such as swallowing mechanism, side effects of the treatment, age; 5) During chemotherapy, nutrition must be checked and assessed at each cycle; 6) During surgery, enteral feeding must be stopped and nasogastric feeding progressively introduced starting on day 1 post-operatively. The quality of feed must be adequate during all the healing period. Close surveillance of fever and regurgitation allows regular review of the amount and nature of enteral feed to be given; 7) The patients are given individualised and written advice at the end of treatment and the nutritional follow-up must be planned.

Age Factors↗

PubMed2001

Management of asthma in children.

The prevalence of asthma in children has increased 160 percent since 1980, and the disease currently affects nearly 5 million children in the United States. The National Asthma Education and Prevention Program provides guidelines for improved asthma care. The goals of this program are to limit the frequency, severity and costliness of asthma exacerbations through extensive education of physicians, children and caregivers. The four components of asthma management include regular assessment and monitoring, control of factors that contribute to or aggravate symptoms, pharmacologic therapy and education of children and their caregivers. The guidelines recommend a stepwise approach to pharmacologic treatment, starting with aggressive therapy to achieve control and followed by a "step down" to the minimal therapy that will maintain control. Quick relief of symptoms can be achieved preferentially by the use of short-acting beta2 agonists. Medications for long-term control should be considered for use in children with persistent symptoms. Inhaled corticosteroids are the most potent long-term anti-inflammatory medications. Other options include long-acting beta2 agonists, cromolyn sodium and nedocromil, antileukotriene agents and theophylline. All have advantages and disadvantages in individual situations.

Anti-Asthmatic Agents↗

PubMed2006

[Statins (HMG-CoA reductase inhibitors)].

Diabetic patients frequently show lipid abnormalities that include qualitative changes in lipid profile. Given the greatly increased risk of coronary heart disease (CHD) in diabetic patients with hyperlipidemia, most principal clinical guidelines recommend aggressively lowering lipid levels in such patients. In fact, several large-scale clinical intervention trials have successfully shown that lipid-lowering agents, particularly statins, could significantly reduce the CHD risk in diabetic patients with hyperlipidemia. According to our investigation on 9,000 Japanese diabetic patients, about a half had hyperlipidemia but only less than half of the hyperlipidemic patients received some lipid-lowering agents. Taken together, it should be concluded that more stringent and aggressive intervention should be recommended in the treatment of Japanese diabetic patients with hyperlipidemia.

Clinical Trials as Topic↗

PubMed1999

From the life-cycles of clinical evidence to the learning curve of clinical experience.

Treatments on offer to an individual with suspected disease are based on concepts which, like products, go through life-cycles (introduction, growth, maturity, decline). We argue that randomized controlled trials, meta-analyses, and guidelines have reached maturity and/or are already on the decline and note renewed interest in case reports and qualitative medicine. The latter emphasize individual rather than 'average' patients. Moreover, we point out that scientific evidence relates not only to variables that can be measured but also to categorical variables that are often neglected. An appropriate treatment strategy is probably one which is indicated by several methods based on different concepts rather than by a single standard method. The doctor's role is to use his critical judgement and experience to appraise evidence from formal trials and from analyses of observational data and to share his views with the patient.

Clinical Protocols↗

PubMedDate not supplied

Current practice in renal anaemia management: two multinational surveys.

The European Best Practice Guidelines recommend that 85% of patients with standard causes of chronic renal failure should achieve a target haemoglobin concentration of > or = 11 g/dL. However, patient outcomes need to be improved as many patients respond suboptimally to treatment and fail to reach these targets. Two multinational surveys of nursing practice in the management of renal anaemia in northern (with comparative data from Australia) and southern Europe were conducted. The aim was to assess variations in the role and amount of responsibility delegated to nurses in renal units throughout Europe and Australia. Patient care could be optimised by developing formal training and educational programmes for nephrology nurses and this has already occurred in many units in the UK.

Anemia↗

PubMed2003

[Optimized diabetes therapy in type 2 diabetics].

BACKGROUND: With the prevalence of type 2 diabetes mellitus having increased to approximately 8% during recent years and a further rise likely, type 2 diabetes will develop into a major health care problem in Europe. There are roughly 8 million diabetics in Germany, with another 4 million estimated unknown case. CLINICAL FEATURES: Diabetes is an accepted risk factor in the development of micro- and macrovascular complications. These complications generate enormous costs in our health care system. The optimal treatment of diabetic complications will minimize the cost to the health care system in the long run. Therefore, it is necessary to relay current therapeutic guidelines to medical personnel on a widespread basis. AIMS AND CONCLUSION: This publication summarizes current therapeutic options in glycemic control of type 2 diabetics which correspond to 95% of all diabetics. Recently, a national guideline has been developed by the "Arzneimittelkommission der deutschen Arzteschaft", the "Deutsche Diabetes- Gesellschaft", the "Fachkommission Diabetes Sachsen", the "Deutsche Gesellschaft für Innere Medizin e. V.", and the "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften". In this guideline, treatment recommendations are made according to the criteria of evidence-based medicine. It is the basis of this review. In addition, the significance of the modern option of functional insulin therapy (FIT) in the treatment of type 2 diabetes will be explained. In closing, innovative alternatives of applying insulin will be discussed. Unquestionably, all other risk factors such as hypertension and/or hyperlipidemia also have to be treated optimally. These risk factors will not be discussed in this publication.

Adolescent↗

PubMed2000

[Scandinavian guidelines for management of minimal, mild and moderate head injuries].

The Scandinavian Neurotrauma Committee (SNC) was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients. A MEDLINE search identified 475 papers dealing with the management of minimal, mild and moderate head injuries. Fourty-two studies presenting Class II evidence on the initial management of such injuries were reviewed and management guidelines were developed. Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness (LOC), Glasgow Coma Scale (GCS) score 15) can be safely discharged. Routine early CT scan is recommended in cases with mild injuries (history of LOC, GCS 14-15) and patients with normal scans may be discharged. CT scan and admission is mandatory in moderate injuries (GCS < or = 13). All patients harbouring additional risk factors should be scanned and admitted. A flow chart for clinical decision making and a Head Injury Instruction card are introduced.

Consciousness↗

PubMed2000

Australian Infection Control Association members' use of skills and resources that promote evidence-based infection control.

BACKGROUND: To adopt an evidence-based approach, professionals must be able to access, identify, interpret, and critically appraise best evidence. Critical appraisal requires essential skills, such as computer literacy and an understanding of research principles. These skills also are required for professionals to contribute to evidence. METHODS: In 1996, members of the Australian Infection Control Association were surveyed to establish a profile including the extent to which they were reading infection control publications, using specific documents for policy and guideline development, developing and undertaking research, publishing research, and using computers. The relationships between demographics, computer use, and research activity were examined. RESULTS: The response rate was 63. 4% (630/993). The study group comprised mostly women (96.1%), and most (66.4%) were older than 40 years of age. Median infection control experience was 4 years (mean, 5.4 years; range, <12 months to 35 years). When developing guidelines and policies (92.7%; 584/630), infection control professionals reviewed State Health Department Infection Control Guidelines and Regulations. Research relating to infection control was undertaken by 21.5% (135/628) of the sample, and 27.6% (37/134) of this group published their research findings. Of the respondents (51.1%; 318/622) who used a computer to undertake infection control tasks, the majority (89.0%) used a personal computer for word processing. CONCLUSION: Regardless of infection control experience, Australian infection control professionals must be adequately prepared to contribute to, access, appraise, and where appropriate, apply best evidence to their practice. We suggest that computer literacy, an understanding of research principles, and familiarity with infection control literature are three essential skills that infection control professionals must possess and regularly exercise.

Adult↗

PubMedDate not supplied

Catheter-associated urinary tract infections: primary care guidelines.

In primary and community health care settings, long-term (> 28 days) urinary catheterisation (LTC) is most commonly used in managing older people and those with neurological conditions. Studies suggest that in the UK LTC is used in 0.5 per cent of people aged 75 or over (Kohler-Ockmore and Feneley, 1996) and in four per cent of people receiving domiciliary care (Getliffe and Mulhall, 1991). Most health-care associated infections (HAIs) are caused by indwelling urinary catheters (Stamm, 1998). Many of these infections are serious and lead to significant morbidity. In acute care facilities, 20-30 per cent of catheterised patients develop bacteriuria, of whom two to six per cent develop symptoms of urinary tract infections (UTIs) (Stamm, 1998).

Anti-Infective Agents, Urinary↗

PubMedDate not supplied

A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer.

PURPOSE/OBJECTIVES: To determine whether research-based recommendations can be made about the clinical management of depression in patients with cancer. DATA SOURCES: Reports of scientific studies, qualitative or quantitative systematic reviews of scientific studies, and practice guidelines published from 1980-2000. DATA SYNTHESIS: In all, 36 pieces of evidence supported the conclusion that psychoeducational interventions benefit depressive symptoms. Evidence included two well-conducted meta-analyses and nine well-designed randomized clinical trials with large samples (N > 100). With regard to intervention content, 70% of behavior therapy studies and 66% of counseling studies drew conclusions that supported the hypothesis. In addition, 58% of studies that tested behavior therapy or counseling in combination with cancer education had positive results. CONCLUSIONS: The evidence supports the conclusion that psychoeducational interventions reduce depressive symptoms in patients with cancer and that behavior therapy or counseling alone or in combination with cancer education is beneficial. IMPLICATIONS FOR NURSING PRACTICE: Nurses can select from a variety of educational, behavioral, and counseling techniques to prevent or manage depression in their patients.

Attitude to Health↗

PubMed1997

National Kidney Foundation report on dialyzer reuse. Task Force on Reuse of Dialyzers, Council on Dialysis, National Kidney Foundation.

The Council on Dialysis of the National Kidney Foundation convened an expert panel to evaluate the current practice and literature related to the reuse of hemodialyzers. The panel reviewed and evaluated literature related to reuse since the last report of the National Kidney Foundation recommendations on reuse was published in 1988. The group sought to develop a consensus concerning the effect of reuse of hemodialyzers on mortality; the efficiency of delivered hemodialysis when reused hemodialyzers are used in the clinical setting; the clinical effects of reused dialyzers as compared with dialyzers not reused on intradialytic symptoms; infections in patients using reused dialyzers; and the effect of reused dialyzers on complement activation, cytokine production, and beta2-microglobulin metabolism and clearance. In addition, the panel reviewed the literature on the potential toxicity of germicides used in the processing of dialyzers for reuse as well as recent changes in federally mandated regulations concerning labeling of dialyzers for reuse, the monitoring of the reuse process, and the effectiveness of reused dialyzers to achieve a prescribed delivered clearance as estimated by urea kinetic modeling or by percent urea reduction. The National Kidney Foundation takes no position for or against dialyzer reuse. The principal reason for the practice of reuse is economical. In view of the uncertainties related to the safety and biological impact of reuse procedures, the task force recommends that a full discussion of the issue of reuse and its potential beneficial and detrimental effects be undertaken with each patient. There is no conclusive evidence to substantiate the notion that either morbidity or mortality associated with single use or reuse is different. Microbial contamination of the water used for dialyzer reprocessing increases patient morbidity. The chemical quality of water used for dialyzer reprocessing should, at least, fall within the same standards as those recommended for product water intended for hemodialysis. Dialyzers should not be reprocessed from patients who have tested positive for hepatitis B surface antigen. The effects of reprocessing high-flux dialyzers on beta2-microglobulin clearance are dependent on the reprocessing technique, the number of reuses, and the nature of the dialyzer membrane used. There are insufficient data on the effects of reuse on beta2-microglobulin behavior to make uniform recommendations. Untoward effects of reused dialyzers may still occur in spite of rigorous adherence to the AAMI guidelines. For example, use of the total cell volume method for assessing changes in small molecule clearances will not show the loss of performance attributable to dialysate shunting. For this reason, the measurement of Kt/V for urea as recommended by the AAMI or the determination of the urea reduction ratio (URR) is strongly recommended at least monthly to gauge the adequacy of the dialysis procedure. Given the significant fall in dialyzer efficiency for urea removal that can occur after repeated uses of a dialyzer, dialysis prescriptions in units practicing reuse should be designed to deliver a Kt/V or URR value that exceeds the dose used for patients treated with single-use dialyzers to make allowance for any possible reuse-induced reduction in dialyzer efficiency. Technicians and other personnel responsible for the reprocessing of dialyzers should receive proper training. These health care providers should be certified in reprocessing by an examining body so that professional competency can be assured.

Bacterial Infections↗

PubMed2005

Exercise and hypertension.

BACKGROUND: Exercise is advocated for the prevention, treatment and control of hypertension. However, the treatment effect of exercise on hypertension is difficult to determine as many studies are poorly controlled and involve small sample sizes. OBJECTIVE: This article reviews current knowledge about exercise and blood pressure (BP), and provides a guideline for exercise prescription that considers the health status and age of the patient. DISCUSSION: An evidence based literature analysis by the American College of Sports Medicine indicates that an isolated exercise session (acute effect) lowers BP an average of 5-7 mmHg. Depending upon the degree the patient's BP has been normalised by drug therapy, regular aerobic exercise significantly reduces BP the equivalent of 1 class of antihypertensive medication (chronic effect). For most hypertensive patients exercise is quite safe. Caution is required for those over 50 years of age, and those with established cardiovascular disease (CVD) (or at high CVD risk) and in these patients, the advice of a clinical exercise physiologist is recommended.

Adult↗

PubMed1999

Using a flow sheet to improve performance in treatment of elderly patients with type 2 diabetes.

BACKGROUND AND OBJECTIVES: Numerous studies have shown that physicians do not provide all the preventive and therapeutic care recommended for patients with diabetes. This study determined if use of a medical record flow sheet could increase compliance with seven quality-of-care indicators developed by the American Diabetes Association. METHODS: Subjects included Medicare enrollees with type 2 diabetes. Following an analysis of baseline data, physicians in the practice used a flow sheet that contained recommended guidelines for diabetes care. Staff inserted the flow sheet into the records of patients included in the baseline sample. Physicians and staff also received education about use of the flow sheet. The post-intervention sample consisted of the same subjects, if they had been seen by the practice during a 3-month period. RESULTS: The records of 114 subjects were reviewed at baseline. Of these subjects, 109 received care during the study period. Improvement was shown in six of the seven quality indicators and was also observed in the performance of post-intervention rates for patients whose flow sheet was used, compared with those for whom it was not used. CONCLUSIONS: The results indicate that education and performance in diabetes care can improve with the use of a flow sheet.

Aged↗

PubMed2001

[Asthma followup in consultation].

Development and application of guidelines for asthma management and prevention should prevent exacerbation, avoid hospitalisations, maintain an optimal lung function, and guarantee a good quality of life in asthmatic patients. Unfortunately, there is a gap between these objectives and the patient's perspectives because of difficulties to organise and deliver care with the issues of the health professional formation, patient education and compliance to chronic treatments. The objectives of the follow-up visit for asthmatic patients are three fold: check for the control of asthma, review and optimise medical treatment, and control asthma management skills. Self-monitoring based of symptoms and/or peak expiratory flow recordings coupled with a written action plan and regular medication review has been shown to significantly reduce exacerbation rate and allows a control of the disease.

Asthma↗

PubMed2004

Evidence-based guidelines for the management of neutropenia following outpatient hematopoietic stem cell transplantation.

Hematopoietic stem cell transplantation (HSCT) involves the transfer of stem cells to establish hematopoiesis in patients who have received myeloablative chemotherapy with or without whole body irradiation. Following high-dose therapy and HSCT, all patients experience a period of neutropenia. Outpatient care delivery models place expanded responsibilities on patients and their families for the management of this treatment side effect. Proactive management of neutropenia is critical to decrease the depth and duration of neutropenia following HSCT, limit exposure to opportunistic and nosocomial pathogens, and ensure prompt intervention should febrile neutropenia or infection develop. Patient and family education, psychosocial support, and coordination of care are key nursing responsibilities.

Ambulatory Care↗

PubMed2005

Intraclass correlation coefficients for cluster randomized trials in primary care: the cholesterol education and research trial (CEART).

Cluster randomization trials are increasingly being used in primary care research. The main feature of these trials is that patients are nested within large clusters such as physician practices or communities and the intervention is applied to the cluster. This study design necessitates calculation of intraclass correlation coefficients in order to determine the required sample size. The purpose of this study is to determine intraclass correlation coefficients for a number of outcome measures at the primary care practice level. The CEART study is a randomized trial testing the effectiveness of translating ATP III guidelines into clinical practice, with primary care physician practices as the unit of randomization and patients as the unit of data collection. The intraclass correlation coefficient (ICC) was<0.02 and the design effect ranged from 1.0 to 2.3, respectively, for weight, total cholesterol, LDL, non-HDL, glucose, creatinine, and % at non-HDL goal. For smoking status, body mass index, systolic blood pressure, HDL cholesterol triglycerides, total cholesterol/HDL ratio and % at LDL goal, the ICC was 0.02-0.047 and the design effect was 2.6-4.1. The largest ICCs (0.05-0.12) and design effects (4.4-9.4) were found for height and diastolic blood pressure. These findings suggest that cluster randomization may substantially increase the sample size necessary to maintain adequate statistical power for selected outcomes such as diastolic blood pressure studies compared with simple randomization for most outcomes evaluated in this study where the design effect is small to moderate. Overall, the ICCs presented will be useful in calculating sample sizes at the primary care level.

Adult↗

PubMed2004

Radiation safety guidelines for radioimmunotherapy with yttrium 90 ibritumomab tiuxetan.

Radioimmunotherapy is a new cancer therapy that combines the cytotoxicity of radiation with the tumor-specific targeting of monoclonal antibodies. Yttrium 90 (Y-90) ibritumomab tiuxetan (Zevalin, IDEC Pharmaceuticals Corporation, San Diego, CA) is indicated for the treatment of patients with relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma (NHL), including patients with rituximab-refractory follicular NHL. Y-90 ibritumomab tiuxetan requires only universal safety precautions and does not impose undue risks or radiation safety restrictions on patients or healthcare workers. The ibritumomab tiuxetan regimen can be administered safely in an outpatient setting. Nurses should become familiar with the necessary precautions in caring for patients treated with Y-90 ibritumomab tiuxetan, both to educate patients about safety issues and to minimize the risk of radiation exposure to staff and others.

Ambulatory Care↗