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PubMed2006

Overactive bladder: The importance of new guidance.

Overactive bladder (OAB) affects an estimated 49 million people in Europe, but only a minority receive appropriate treatment. Others are bothered by unacceptable levels of symptoms that severely impair their quality of life and represent a significant financial burden to themselves and to their healthcare providers. Recently updated guidelines from the International Consultation on Incontinence (ICI) and the European Association of Urology (EAU) take account of important new developments in the management of bladder problems in both primary and secondary care. However, local implementation of previous guidance has been variable, with many patients with OAB and other bladder problems failing to gain full benefit from current clinical and scientific understanding of these conditions. The recent expansion of the range of treatments available for OAB and stress urinary incontinence makes it especially important that physicians become aware of the differential diagnosis of these conditions - the questions they need to ask, and the investigations which will help determine the most appropriate course of action.

Algorithms↗

PubMed2002

[Smoking cessation: practice guidelines].

Smoking is a habit sustained and amplified by dependency on nicotine. Despite knowing the risks to their health, smokers have great difficulty in stopping. The syndrome of nicotine withdrawal and the related complications when stopping smoking: depression, weight gain, are adequate justifications of the many failures to stop smoking. However, we have now come out of the empiricism, effective treatment is available and scientifically validated international recommendations have been established. They involve: the practice of minimal advice which consists of questioning every patient about smoking habits and encouraging them to stop; the treatments of nicotine substitution, patch, chewing gum, tablets or inhaler, used at effective dosage and sometimes in association with each other; more recently, Bupropion (Zyban, LP), a psychotropic inhibitor of Dobutamine and Noradrenalin recapture; behavioural and cognitive therapies, alone or in association with pharmacological therapy. The measurement of the score of tobacco dependency with the Fagerström test enables definition of a therapeutic strategy. Of course, these treatments are only effective in smokers motivated to stop smoking. The decision to stop smoking should only be taken after a period of reflection during which the role of information and advice given by all health professionals is primordial. Also, the long-term follow-up and counsel are essential to prevent relapse, especially during the first year.

Counseling↗

PubMed1998

Implementing the guidelines for adolescent preventive services.

The Guidelines for Adolescent Preventive Services (GAPS) include recommendations developed and promoted by the American Medical Association's Department of Adolescent Health and are intended to organize, restructure and redefine health care delivery for 11- to 21-year-old patients. Data show that health risks in this age group are more social in origin than medical, and that these unhealthy behaviors can be recognized and interventions can be applied at an earlier age to reduce adolescent mortality and morbidity. In fact, evidence suggests that some interventions may result in a decrease in premature adult mortality. GAPS provides physicians with preventive service recommendations and a flow sheet that is useful for implementing and documenting these services during office visits. This system enables the busy physician to identify at-risk adolescent patients and provide them with information about changing unhealthy behaviors

Adolescent↗

PubMed1999

Treatment guidelines for primary nonretentive encopresis and stool toileting refusal.

Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and retention. This form of encopresis accounts for up to 20 percent of all cases. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. An organic cause for nonretentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent. A full developmental and behavioral assessment should be made to establish that the child is ready for intervention to correct encopresis and to identify any barriers to success, particularly disruptive behavior problems. Successful interventions depend on the presence of soft, comfortable bowel movements and addressing toilet refusal behavior. Daily scheduled positive toilet sits are recommended. Incentives may be used to reinforce successful defecation during these sits. A plan for management of stool withholding should be agreed on by the parents/caretakers and the family physician before intervention.

Child Behavior Disorders↗

PubMed2003

Update on the National Cholesterol Education Program Adult Treatment Panel III guidelines: getting to goal.

Considerable data on the pathophysiology, epidemiology, and treatment of dyslipidemia-induced coronary heart disease (CHD) have accumulated in recent years. These data have been assessed and incorporated into the guidelines of the National Cholesterol Education Program Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel [ATP] III). A major focus of the new guidelines is the assessment of the near-term (i.e., 10-yr) risk of experiencing a CHD event and matching the intensity of treatment to this risk. Patients with diabetes and those with a greater than 20% 10-year risk of experiencing a CHD event have been elevated to the risk level of CHD equivalent. The ATP III guidelines also modify several lipid and lipoprotein classifications. A low-density lipoprotein cholesterol (LDL) level below 100 mg/dl is now considered optimum for all individuals. In addition, high-density lipoprotein cholesterol (HDL) and triglyceride cutoff points have been modified to reflect more accurately the risk associated with abnormalities in these lipoproteins. As with the previous guidelines, the primary target of therapy remains LDL. Therapeutic lifestyle changes consisting of diet, weight reduction, and increased physical activity should be included in all treatment regimens. Based on their potent LDL-lowering properties and their proven ability to decrease mortality in a variety of patient populations, statins are generally the first choice for pharmacologic therapy. A secondary target of therapy includes non-HDL goals for patients with high triglyceride levels and the metabolic syndrome, which is characterized by abdominal obesity, elevated triglyceride levels, low HDL levels, and insulin resistance. Management of these secondary targets includes weight reduction and increased physical activity, and treatment of the lipid and nonlipid risk factors. Overall, ATP III represents an aggressive approach to treating dyslipidemia, greatly extending the number of individuals who qualify for treatment.

Cholesterol, HDL↗

PubMed2006

The evidence base behind modern fasting guidelines.

Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents, thus decreasing the risk of regurgitation/aspiration. The objectives of the Cochrane report which are summarised in this paper, were to systematically review the effect of different preoperative fasting regimes (duration, type and volume of intake) on perioperative complications and patient wellbeing. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety ie. intraoperative gastric volume and pH. There was no evidence to suggest intake of fluids up to 2 hr preoperatively has an impact on patients gastric volumes or pH. Intake of fluids up to 90 min preoperatively had no impact on gastric contents but this was based on small numbers. In addition, permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Clinicians should evaluate this evidence for themselves and when necessary, adjust existing fasting policies.

Clinical Trials as Topic↗

PubMed2000

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care.

OBJECTIVE: The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers. STUDY DESIGN: After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy. RESULTS: A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%). CONCLUSIONS: The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.

Cotinine↗

PubMed2005

The "minimizing antibiotic resistance in Colorado" project: impact of patient education in improving antibiotic use in private office practices.

OBJECTIVE: To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practices. DATA SOURCES/STUDY SETTING: Antibiotic prescription rates based on claims data from four managed care organizations in Colorado during baseline (winter 2000) and study (winter 2001) periods. STUDY DESIGN: A nonrandomized controlled trial of a household and office-based patient educational intervention was performed. During both periods, Colorado physicians were mailed antibiotic prescribing profiles and practices guidelines as part of an ongoing quality improvement program. Intervention practices (n=7) were compared with local and distant control practices. DATA COLLECTION/EXTRACTION METHODS: Office visits were extracted by managed care organizations using International Classification of Diseases-9-Clinical Modification codes for acute respiratory tract infections, and merged with pharmacy claims data based on visit and dispensing dates coinciding within 2 days. PRINCIPAL FINDINGS: Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practices, and decreased from 39 to 37 percent at the local control practices, and from 34 to 30 percent at the intervention practices (p=.18 compared with distant control practices). Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practices, from 55 to 45 percent at the local control practices, and from 60 to 36 percent at the intervention practices (p<.002 and p=.006 compared with distant and local control practices, respectively). CONCLUSIONS: In office practices, there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis. In contrast, patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts.

Acute Disease↗

PubMed2001

Overview of evidence-based medicine: challenges for evidence-based laboratory medicine.

Evidence-based medicine (EBM) has been driven by the need to cope with information overload, by cost-control, and by a public impatient for the best in diagnostics and treatment. Clinical guidelines, care maps, and outcome measures are quality improvement tools for the appropriateness, efficiency, and effectiveness of health services. Although they are imperfect, their value increases with the quality of the evidence they incorporate. Laboratory professionals must direct more effort to demonstrating the impact of laboratory tests on a greater variety of clinical outcomes. Laboratory and clinical practitioners must be familiar with many of the accessible electronic and paper tools for searching for evidence. Detailed statistical and epidemiologic knowledge is not essential, but critical appraisal skills and a competent understanding of the strengths and weaknesses of systematic review and metaanalysis are necessary. Overemphasis on complexity and failure to recognize time limitations are major barriers to translating EBM into everyday practice. Emphasizing and practicing the role of the laboratory professional as a skilled clinical consultant strongly grounded in evidence as well, in addition to better integration of laboratory and clinical information and improved laboratory reports will overcome most barriers. There is a poverty of good, primary studies of test evaluations. Institution of more consistent standards for the design and reporting of studies on diagnostic accuracy should improve the situation. If nothing else, systematic reviews have demonstrated the need for more good-quality primary research in laboratory medicine.

Chemistry, Clinical↗

PubMedDate not supplied

[Allergic Rhinitis and its Impact on Asthma (ARIA) in Latin America].

Allergic rhinitis is the commonest chronic respiratory disorder in children and young adults having an important impact for those suffering this condition, as well as for the public health. Allergic rhinitis is frequently associated to other co-morbidities, particularly asthma and conjunctivitis but, also, sinusitis and otitis media. Most of patients suffering rhinitis are cared by GPs and pediatricians and there are evidences that allergic rhinitis is undertreated, particularly the moderate/severe persistent forms. Clinical guidelines have become an important tool providing recommendations for diagnosis and treatment of different medical conditions. They help the process of decision making for GPs and pediatricians, and many of them, contain an update on basic science and epidemiology. In respiratory medicine, guidelines on asthma and rhinitis are available; however, they do not look at the patients globally and focus the disorder on an organ-specific basis without recommendations on co-morbidities. ARIA, Allergic rhinitis and its impact on asthma, has not been developed only to update specialists in allergy/immunology, otorhinolaryngology and neumology on rhinitis and its comorbidities but, also, to provide recommendations for non-specialists. A new classification and severity of allergic rhinitis is proposed replacing the classic perennial and seasonal forms for persistent and intermittent, mild to moderate/severe. ARIA is an initiative in collaboration with the World Health Organization and the master document has been endorsed by many national and international scientific societies and organizations. ARIA is an evidence-based document also stressing on pediatric aspects and providing recommendations for low-income countries.

Algorithms↗

PubMed2005

[Education for chronic cardiologic diseases in a transversal multidisciplinary unit: the experience of a general hospital center].

Treatments for congestive heart failure, hypertension and cardiovascular risk have significantly changed and have become more complex. The have also become more and more effective thanks to the results of great clinical studies that have enabled European and North-American societies to issues recommendations. The observance of the pharmacological and non-pharmacological treatments requires the education of patients and their family following guidelines that have been clearly defined by the European Society of Cardiology. This education, in which the technic of communication is very important, is common to a lot of chronic diseases and requires adequate material and human resources in order to have an optimal quality of treatment. In a society in which spending is on rise, getting such resources is not easy. However, putting in common resources of several departments can be a good solution. The experience of the Hospital Center of Douai (France) lead to the creation of a Transversal Education Unit at the end of the year 2003. This unit centralizes the efforts of several departments of care like pneumology, pediatrics, diabetology, nutrition and cardiology and allows patients suffering from co-morbidities to have access to various programs of this unit.

Cardiac Rehabilitation↗

PubMed2004

An ongoing six-year innovative osteoporosis disease management program: challenges and success in an IPA physician group environment.

The goal of this ongoing comprehensive osteoporosis disease management initiative is to provide the adult primary care physicians' (PCPs) offices with a program enabling them to systematically identify and manage their population for osteoporosis. For over six years, Hill Physicians Medical Group (Hill Physicians) has implemented multiple strategies to develop a best practice for identifying and treating members who were candidates for osteoporosis therapy. Numerous tools were used to support this disease management effort, including: evidence-based clinical practice guidelines, patient education sessions, the Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire tool, member specific reports for PCPs, targeted member mailings, office-based Peripheral Instantaneous X-ray Imaging (PIXI) test and counseling, dual x-ray absorptiometry (DEXA) scan guidelines, and web-based Electronic Simple Calculated Osteoporosis Risk Estimation (eSCORE) questionnaire tools. Hill Physicians tabulated results for patients who completed 2649 SCORE tests, screened 978 patients with PIXI tests, and identified 338 osteopenic and 124 osteoporotic patients. The preliminary results of this unique six-year ongoing educational initiative are slow but promising. New physician offices express interest in participating and those offices that have participated in the program continue to screen for osteoporosis. Hill Physicians' message is consistent and is communicated to the physicians repeatedly in different ways in accordance with the principles of educational outreach. Physicians who have conducted the program have positive feedback from their patients and office staff and have begun to communicate their experience to their peers.

Absorptiometry, Photon↗

PubMed1998

What works? Success stories in Type 2 diabetes mellitus.

The increasing prevalence of Type 2 diabetes mellitus has made diabetes a major public health problem worldwide. Healthcare systems are faced with the major challenge of developing innovative approaches to improving the prevention of diabetes and associated complications, particularly in populations undergoing rapid cultural development. Examples of community-based primary prevention projects in two Native communities in Canada that have high incidences of diabetes are reviewed. These projects are notable for the active participation of the communities, the collaborative relationship that was established between the communities and the researchers, and the way that traditional native culture and beliefs were incorporated into the intervention design. This phenomenon has impacted on the success of the projects and has enhanced their long-term sustainability.

Canada↗

PubMedDate not supplied

Guidelines for the diagnosis and treatment of celiac disease in children.

Jennifer, age 2 years, is being seen for her regular 2-year well child visit. You note her weight is only at the 5% and has been dropping percentiles over the past year When you ask her mother about Jennifer's diet, she reports Jennifer is a "picky eater" and often complains of a "stomach ache." Her mother reports her stomach looks "bloated. " Steven, age 7 years, is brought into the clinic because of recurrent abdominal pain with occasional constipation or diarrhea. Steven's mother had been told in the past that he probably had "irritable bowel syndrome" but changes in his diet, occasional use of a laxative, and relaxation techniques have not improved his symptoms. Rebecca, age 12 years, is brought into your clinic because her mother has recently learned that two first cousins have been diagnosed with celiac disease. She is wondering if Rebecca should be screened for this condition since she has heard it runs in families.

Abdominal Pain↗

PubMed2005

Rationale for new American Diabetes Association Guidelines: are national cholesterol education program goals adequate for the patient with diabetes mellitus?

Both the American Diabetes Association (ADA) and the National Cholesterol Education Program (NCEP) consider type 2 diabetes mellitus to be a coronary artery disease (CAD) risk equivalent and thus suggest that patients with either diabetes or CAD should have their plasma levels of low-density lipoprotein (LDL) cholesterol lowered to <2.59 mmol/L (<100 mg/dL). Recently the NCEP issued a white paper suggesting an even lower plasma LDL cholesterol goal of <1.81 mmol/L (<70 mg/dL) for patients at high cardiovascular risk, including patients with diabetes. This rationale was based partly on the higher risk of future cardiovascular disease seen in patients who have diabetes with or without preexisting cardiovascular disease than in nondiabetic subjects with preexisting cardiovascular disease. Additionally, as reported in the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) study, high-dose lipid-lowering therapy has been shown to further reduce CAD event rates compared with conventional therapy.

Cholesterol, LDL↗

PubMed2004

Designing an acupuncture study to meet evidence-based medical criteria: methodological considerations for logistic design and development of treatment interventions arising from the German randomized controlled acupuncture trial on chronic shoulder pain (GRASP).

The results from studies on potential treatment effects of acupuncture are often limited due to serious difficulties in methodology. Randomized controlled trials on acupuncture should test a widely accepted treatment strategy of verum and sham acupuncture. However, in clinical practice various patterns of acupuncture techniques are employed, and up to now no generally accepted guidelines on how to perform a reliable verum or sham treatment have been established. Another limitation is that in most studies the study populations are too small to obtain reliable data and to detect subtle differences between the unspecific needling of sham acupuncture and specific needling of verum acupuncture with sufficient statistical power. Moreover, only a multicenter trial in an outpatient setting would guarantee a naturalistic environment in which acupuncture is used in clinical practice. In the present report we discuss such methodological aspects in detail and summarize some practical considerations for planning an acupuncture trial that fulfills evidence-based medical criteria. The largest German study on the treatment effects of acupuncture in patients with chronic shoulder pain (recruited patients n = 452), might serve as an example for such a well-designed study. Before we could conduct our study, clear definitions and protocols for the verum and sham acupuncture treatments as well as adequate endpoints had to be developed. For this we used a combination of a comprehensive study of the literature and structured interviews with experienced physicians followed by an expert panel. A total of 41 physicians had to be trained to achieve a homogeneously high quality of acupuncture treatment. The latter represents a prerequisite for reproducibility, constituting a critical component of rigorous efficacy trials in scientific acupuncture research.

Acupuncture Therapy↗

PubMed2005

[Treatment of exacerbation of asthma: what are today's issues?].

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

Acute Disease↗

PubMed2006

Dose counting and the use of pressurized metered-dose inhalers: running on empty.

BACKGROUND: Pressurized metered-dose inhalers (pMDIs) are the cornerstone of asthma treatment. The pMDI is an economic and portable medication delivery system, but the device does not indicate how much medicine remains in the canister once a patient starts using it. OBJECTIVE: To determine how patients evaluate the contents of their pMDI and whether they are either discarding inhalers when medication remains or using inhalers beyond the indicated number of doses. METHODS: This study was conducted in April 2003 via a 6.5-minute telephone interview with a random sample of 500 families with asthma from across the United States. RESULTS: Of the 500 respondents participating in the telephone interview, nearly one third (31.6%) named an inhaled corticosteroid or bronchodilator and inhaled corticosteroid combination as the inhaler used when wheezing, coughing, or short of breath. Respondents using a bronchodilator (n = 342) varied in the frequency with which they use their pMDIs: 31.9% daily, 18.7% weekly, 23.4% monthly, and 23.1% less than once per month. More than half (53.8%) of bronchodilator users refill their prescriptions more frequently than recommended by national guidelines. Only 36% of bronchodilator users reported ever having been told to keep track of pMDI doses used. Of those, 79% had been advised to do so by a physician, 6% by a pharmacist, and 3% by a nurse. Eighty-seven (25%) of the 342 respondents who named a bronchodilator reported having found their pMDI empty during an asthma exacerbation. Seven of those patients had to call 911. Of these 87 patients, 71 (82%) considered their pMDI empty when absolutely nothing came out. CONCLUSIONS: Patients do not have a reliable means of monitoring the contents of their metered-dose inhalers, which is causing serious problems that need to be addressed. Given the necessity of a reliable dose counting method, it is clear that manufacturers should include dose counters as a standard feature of every metered-dose inhaler.

Adolescent↗