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PubMed1999

Making weaning easier. Pathways and protocols that work.

Clinical pathways and weaning protocols are useful tools for improving the care of patients requiring LTMV. The value of the pathways and protocols rests in large part on the systematic multidisciplinary nature of the tools. Nevertheless, for the pathways and protocols to truly affect outcomes, they must be carefully designed. It is critical that this occurs with the input of experts, and especially in the case of pathways, a seasoned knowledgeable clinician should guide the process. The success of such care delivery models rests with the quality of those who design, test, and revise them. If developed in a careful and thoughtful manner using the best science available, the pathways and protocols may truly be powerful tools for clinical practice.

Benchmarking↗

PubMed2000

[Proposed protocol for the study of cerebrovascular disease in childhood].

AIM: The etiology of cerebrovascular disease in the paediatric population, remains unknown in up to 40% of the cases ("idiopathic"), but recent advances could improve this percentage. We devised a comprehensive study protocol for such investigation aimed at the identification of potentially modifiable risk factors for paediatric stroke. PATIENTS AND METHODS: From the 141 patients initially registered in our data base for stroke population (from January 1984 until December 1995), we invited all the patients with idiopathic cerebrovascular disease to complete the study protocol. New cases appeared from January 1996 until July 1999 were also included. RESULTS: A total of 68 cases were identified. We found an etiology in 38% and in 76% of the cases we found at least one risk factor for stroke. Mild hyperhomocysteinemia was the most frequent risk factor identified (36% of patients versus 5% of controls), one of them an infant with fatal haemorrhagic infarct with classic homocystinuria. 31% of the patients had thrombotic risk factors (protein S, protein C, antithrombine III deficiency, factor V Leiden, etc). 17.6% had unspecific febrile illness at the time of the cerebral infarction and 11.6% had minor head injuries before the stroke. CONCLUSIONS: The use of the protocol improves the identification of potentially modifiable risk factors for stroke in childhood and may serve as a practical guideline for clinicians. The stroke protocol is as important as management strategies for acute stroke or for recurrence prevention, currently under consideration in the adult population.

Adolescent↗

PubMed2001

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol.

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90% of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75% of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Anti-Bacterial Agents↗

PubMedDate not supplied

Inter-comparison of absorbed dose to water in a Co-60 therapy beam using IAEA and HPA protocols.

The absorbed dose water in a Co-60 teletherapy beam has been measured with four different standard ionisation chambers applying two codes of practice and also, with a Fricke dosimeter. Measured values agree generally within 2.3%. There is a remarkable agreement of less than 0.3% variation, between ionisation chambers NE 2561 and NE 2481 when the IAEA protocol is applied. The HPA protocol is applicable to only NE 2561 and a variation of about 1.4% was observed between measurements made with this ionisation chamber applying the two protocols. The IAEA protocol shows very accurate results. With a deviation of about 2.2%, the Frickle dosimeter appears to be the least accurate for therapy dose measurement despite its simplicity of application.

Absorption↗

PubMedDate not supplied

The outcome of implant overdentures from a prosthodontic perspective: proposal for a classification protocol.

PURPOSE: This article proposes a classification protocol for reporting the outcome of implant overdentures. MATERIALS AND METHODS: Review of the literature pertaining to postinsertion prosthodontic procedures for maxillary and mandibular implant overdentures revealed a wide range in the terminology used and methods of reporting outcome, usually as a result of the use of varying designs among different implant systems. A need for comparative evaluation of the prosthodontic success of implant overdentures was identified. RESULTS: An existing classification protocol for implant-fixed prostheses containing six objectively defined fields was modified for implant overdentures. This new protocol, which also uses the descriptive fields of success, survival, unknown, dead, and retreatment (repair or failure), provides a method whereby postinsertion prosthodontic procedures and subsequent time to retreatment can be quantified regardless of design, method of attachment, or implant system. A ratio method for identifying prosthodontic treatment cost effectiveness of implant overdentures is included. CONCLUSION: This protocol could assist clinicians in their choices of implant overdenture therapy by providing accurate comparisons of varying implant overdenture systems and designs, and by identifying prosthodontic treatment cost effectiveness.

Clinical Protocols↗

PubMed2002

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

BACKGROUND: To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. MATERIAL/METHODS: Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. RESULTS: Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. CONCLUSIONS: This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.

Adolescent↗

PubMed2000

[High risk acute lymphoblastic leukaemia in children. Preliminary report after introducing a new version of New York (1997) protocol adjusted to the age of the patients. Report of the Polish Paediatric Leukaemia/Lymphoma Study Group].

The paper presents the experience of the Polish Paediatric Leukaemia/Lymphoma Study Group in the treatment of high-risk acute lymphoblastic leukaemia in children using a new version of the New York (1997-1999). Protocol with treatment intensity adjusted according to the age of the patients. From April 1997 to December 1999 a group of 49 children with leukocytosis ranging from 50 900/mm3 to 580 000/mm3 (median 122 000/mm3) and 6 children with leukocytosis below 50 000/mm3 and poor response to steroids were treated with this protocol. Children below 10 years (43 patients) were treated according to the previous protocol, children above 10 years (12 patients) were treated with intensified protocol (high doses of ARA-C in consolidation and intermediate doses of Mtx in maintenance). Induction was identical for all patients. Complete remission was achieved in 92.6% patients. There were 2 relapses. Six children died - 3 without remission, 2 due to a relapse, 1 due to treatment complications. The current opinions concerning classification of HRG-ALL and treatment possibilities in this group of children are discussed.

Adolescent↗

PubMed2002

Retrospective comparison between CHOP-PVP and CHOP protocols for non-Hodgkin's lymphoma.

OBJECTIVE: To compare the therapeutic effects between CHOP-PVP and CHOP protocols for non-Hodgkin's lymphoma (NHL). METHODS: Of 79 NHL patients, 40 received CHOP-PVP and 39 received CHOP protocol. Kaplan-Meier method was used for survival rate and Cox regression model for prognostic factors. RESULTS: The complete remission rate and overall response rate were 57.5% (23/40) and 87.5% (35/40) in CHOP-PVP group and they were 33.3% (13/39) and 69.2% (27/39) in CHOP group. There was a significant difference (P < 0.05) in the complete remission rate and overall response rate between the two groups. The main toxicity was myelosuppression. The leukocytopenia rate was 82.5% in CHOP-PVP group and 71.8% in CHOP group (P > 0.05) with no fatality in either group. CONCLUSION: CHOP-PVP protocol may be more effective for non-Hodgkin's lymphoma than CHOP protocol without increasing toxicity.

Adolescent↗

PubMedDate not supplied

Experience of the Izmir Pediatric Oncology Group on Neuroblastoma: IPOG-NBL-92 Protocol.

This multicentric study aimed to bring neuroblastoma patients together under IPOG-NBL-92 protocol and evaluate the results within the period between 1992 and 2001 in Izmir. Sixty-seven neuroblastoma patients from 4 pediatric oncology centers in Izmir were included in the study. IPOG-NBL-92 protocol modified from German Pediatric Oncology (GPO)-NB-90 protocol was applied: Patients in stage 1 received only surgery, while surgery plus 4 chemotherapy courses (cisplatin, vincristine, ifosfamide) were given in stage 2 and surgery plus 6 chemotherapy courses (cisplatin, vincristine, ifosfamide, epirubicin, cyclophosphamide) were given in stages 3 and 4 patients. In patients who were kept in complete remission (CR), a maintenance therapy of one year was applied. Radiotherapy was given to the primary site following induction chemotherapy plus surgery in stages 3 and 4 patients with partial remission (PR). The stages of the patients were as follows: 5% in stage 1, 39% in stage 3, 49% in stage 4, and 7% in stage 4S. Primary tumor site was abdomen in 88% of cases. CR rates were as 100% in stage 1, 76% in stage 3, 35% in stage 4, and 75% in stage 4S. Relapse was observed in 32% of patients in a median of 19 months. The median follow-up time for survivors was 33 (17-102) months. Five-year OS rate was 31% and the EFS rate was 30% in all patients. Five-year overall and event-free survival rates were 63 and 30% in stage 3, but 6 and 5%, respectively, in stage 4 patients. Univariate analysis established that the age, stage, primary tumor site, and high LDH and NSE levels conferred a significant difference. The IPOG-NBL-92 protocol has proved to be satisfactory with tolerable toxicity and reasonable CR and survival rates. However, more effective treatments suitable to Turkey's social and economic conditions are urgently needed for children over 1 year of age with advanced neuroblastoma.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2002

Development of a Virtual Private Database for a multi-institutional Internet-based Radiation Oncology Database overcoming differences in protocols.

A multi-institutional Radiation Oncology Greater Area Database (ROGAD) was started in 1991 under the direction of the Japanese Society for Therapeutic Radiology and Oncology (JASTRO). Use of ROGAD was intended to allow reflection of results of data analysis into treatment strategy and treatment planning for individual cases, to provide quality assurance, to maximize the efficacy of radiotherapy, to allow assessment of new technologies or new modalities, and to optimize medical decision making. ROGAD collected 13,448 radiotherapy treatment cases from 325 facilities during the period from 1992 to 2001. In 2000, questionnaires were sent to 725 radiotherapy facilities throughout Japan, to further obtain the situation of the radiation oncology database. Workers at 179 facilities replied that"the protocol of my facility is different from ROGAD protocol and I must send data according to the ROGAD protocol". So, we developed the Virtual Private Database System (VPDS) which is operated as if an oncologist had a database solely owned by his own facility, in spite of actually operating ROGAD. VPDS realizes integration of different plural databases, regardless of differences in entry methods, protocols, definitions and interpretations of contents of clinical data elements between facilities.

Clinical Protocols↗

PubMed2003

Lumbar discectomy: developing and implementing a day surgery protocol.

In some centres, patients who require a lumbar discectomy are successfully discharged the day of surgery. With the ongoing pressure to provide safe care for patients within certain bed limitations, this option was considered. Using a continuous quality improvement method, a prospective review of patients undergoing a single-level lumbar discectomy was monitored. Based on pre-set criteria, patients were included or excluded in the day surgery protocol and both groups were monitored. A large component of nursing education was provided for all patients, and will be highlighted. Data retrieved for both groups included demographics, length of operation, length in recovery room, length of hospital stay required, and the re-admission rate. There were 47 patients monitored over 11 months. Of the 34 patients entered in the protocol, seven required an overnight length of stay. The reasons for the extended length admission will be described. Of the 13 patients excluded from the protocol, one did not require an overnight stay. Following review of the data, the criteria for inclusion of patients into the protocol has been altered and patients can safely proceed with day surgery for lumbar discectomy.

Adult↗

PubMedDate not supplied

Management protocol for scirrhous gastric cancer.

BACKGROUND: The prognosis for patients with scirrhous gastric cancer (SGC) is extremely poor. However, the management protocol for this type of cancer has not been well discussed. In this study, we retrospectively evaluated the management of SGC and we introduced a new treatment protocol for SGC. PATIENTS AND METHODS: Between 1991 and 2001, 58 patients with SGC were treated. Thirty-nine, who underwent gastrectomy, were divided into 3 sub-groups according to peritoneal metastasis (P) and peritoneal washing cytology (CY) status [P(-)/CY(-), P(-)/CY(+), and P(+)/CY(+)]. The survival rates of these 3 sub-groups were compared with patients who did not have a gastrectomy (n=19), retrospectively. From 2002, we started a new treatment protocol for SGC. Laparoscopic diagnosis of P or CY and intraperitoneal chemotherapy (IPC) were performed before performing laparotomy on 10 patients with SGC. RESULTS: The 5-year survival rate of the 19 patients in P(-)/CY(-) was 11.6%. The survival rates of patients with P(-)/CY(+) or patients with P(+)/CY(+) were no different from patients who did not have gastrectomy (pleural effusion or ascites negative). In 10 patients who were treated with the new protocol, 7 with P(-)/CY(-) underwent gastrectomy after IPC and 3 with P(+)/CY(+) underwent repeated IPC. CONCLUSION: Gastrectomy may not have prognostic benefit for patients with SGC with CY(+). Thus, we recommend laparoscopic diagnosis of peritoneal metastasis or peritoneal cytology before performing laparotomy on these patients.

Adenocarcinoma, Scirrhous↗

PubMed2004

Acute Pain Service and multimodal therapy for postsurgical pain control: evaluation of protocol efficacy.

AIM: The institution of a postoperative Acute Pain Control Service is mandatory to improve the control of pain induced by surgical injury. Treatment of postoperative pain may be achieved using a combination of analgesic agents and techniques, reducing the incidence of side effects owing to the lower doses of the individual drugs. In 1997 we established an Acute Pain Service (APS) at the San Raffaele Hospital in Milan. The aim of this study was to assess the efficacy and safety of our APS both in terms of treatment protocols and organisational issues. METHODS: In this prospective observational study we included 592 patients undergoing abdominal, gynecological, or orthopedic surgery with severe expected pain. According to general guidelines on pain treatment, the patients were assigned to different treatment protocols based on the kind of operation. All protocols were based on the multimodal therapy, with the association of nonsteroidal anti-inflammatory drugs (NSAIDS), opioids and regional anesthesia techniques. During the first 48 h of the postoperative period we recorded vital signs, level of pain and occurrence of any side effect. RESULTS: Our analgesic protocols proved to be effective and safe (low incidence of side effects) for every surgery. The incidence of postoperative nausea and vomiting was higher in patients receiving patient-controlled morphine than that with continuous epidural or nerve block. After lower abdominal surgery, pain at movement at 24 h was significantly lower in the epidural group than in the Patient Control Analgesia group. Nausea and vomiting, numbness and paresthesias at the lower limbs were higher in gynecological patients. A larger percentage of orthopedic patients in the epidural group reported numbness and paresthesias at the lower limbs in comparison with patients receiving continuous peripheral nerve block. CONCLUSION: In agreement with previous literature, this study confirmed that a multimodal approach to pain treatment provides an adequate control of postoperative pain, minimizing side effects.

Abdomen↗

PubMed2005

[Treatment results with ALL-BFM-95 protocol in children with acute lymphoblastic leukemia in Hungary].

BACKGROUND: In Hungary children (from 1 to 18 years of age) with de novo acute lymphoblastic leukemia were treated from January 1996 to October 2002, according to protocol ALL-BFM-95. AIM: The aim of this study was to evaluate the experience with this protocol, the treatment results according to the risk groups and to compare the Hungarian data with the international results. METHODS: Patients were stratified into 3 risk groups, based on initial white blood cell count, age, immunology, cytogenetics and response to treatment: standard, medium and high risk group. RESULTS: Three hundred sixty eight children entered the study (male-female ratio was 1.27:1, median age 6 years and 4 months). 110 (29.9%) children were in the standard, 210 (57.1%) in the medium and 48 (13%) in the high risk group. Duration of the chemotherapy was 2 years, except of the boys in the standard risk group, their maintenance therapy was 1 year longer. The overall complete remission rate was 93.2%. 20 (5.4%) children died in induction and 5 (1.4%) were non-responders. The 5-year overall survival for all patients was 78.5%, in the standard risk group 93.2%, in the medium risk group 78.4% and in the high risk group 44.5% with a minimum follow up of 1.19 years and median follow up of 4.85 years. From the 368 patients 272 (73.9%) are still in their first complete clinical remission and other 18 children are alive after relapse. In 14.7% of the patients relapse was diagnosed; the most common site was the bone marrow. In one patient second malignancy occurred. The 5-year event free survival for all patients was 72.6%, in the standard risk group 87.6%, in the medium risk group 72.1% and in the high risk group 39.9%. CONCLUSION: The treatment outcome of children with acute lymphoblastic leukemia improved remarkably over the last decades. 78% of children suffering from acute lymphoblastic leukemia could be cured with the ALL-BFM-95 protocol. The Hungarian results are comparable to those achieved by other leukaemia study groups in the world regarding the ALL-BFM-95 protocol.

Antineoplastic Combined Chemotherapy Protocols↗

PubMedDate not supplied

[A possible protocol for postoperative management in laparoscopic cholecystectomy].

The goal of the "Prospect" programme (sponsored by Pfizer) is to create possible evidence-based protocols related to the management of postoperative pain after certain type of surgical intervention (e.g. hernia repairs, hysterectomies, etc.). This article is introducing the protocol for laparoscopic cholecystectomy for both day-case and longer hospital admission cases. The protocol is designed for preoperative, intra and postoperative period, choosing only those measures which were effective for postoperative pain, published in the literature. We are also presenting an analyze of our 13,000 laparoscopic cholecystectomies, from "Prospect" protocol point of view, and what we should do to improve the management of postoperative pain.

Analgesics↗

PubMed2005

[Treatment results of Langerhans cell histiocytosis with LSH II protocol].

BACKGROUND: The aim of study was to evaluate outcome of international treatment protocol LCH II for children with Langerhans cell histiocytosis treated in FN Motol. METHODS AND RESULTS: Between November 1995 and December 2003, 46 children were treated, sex ratio M:F 29:17 and median age at diagnosis 6 years 8 months. 28 children (60.9%) suffered from monosystem disease with majority of bone lesions (23 times) with skull predominance (16 times). Surgery was primary treatment modality for monosystem disease. Five children with recurrence were successfully treated by protocol LCH II - LR (3x) and LCH III - LR /G2/, respectively. Eighteen children (39.1%) suffered from multisystem disease. 6 out of 18 patients were treated according to low-risk protocol LCH II - LR and 12 children by high-risk scheme LCH II - HR at the non-randomized branch included etoposide. Recurrence was revealed in 11 patients and 10 of them reached 2nd or 3rd complete remission (CR) by 2 - chlorodeoxyadenosine (CDA) monotherapy, and 1 child reached 2nd CR by LCH II - HR scheme. Two children underwent irradiation after bone lesion excision as well as 1 child as supplemental treatment. Totally, 29 children (63.0%) achieved 1st CR, 14 (30.4%) 2nd CR, 2 (4.4%) 3rd CR, and 1 child died because of LCH progression. There were no severe side effects of chemotherapy. Follow-up median time was 5 years 8 months (range 9 months - 9 years 6 months). CONCLUSIONS: LCH II protocol is safe and effective. Results revealed that treatment of patients with multisystem disease might demand some treatment modification.

Adolescent↗

PubMedDate not supplied

Developing clinical protocols for nursing practice: improving nephrology care for children and their families.

Improving and maintaining quality patient care through the development and implementation of clinical protocols is an important facet in our health care system. Identifying the need for clinical protocols, developing and maintaining the protocols, and defining the specific role of pediatric nephrology nurses in this process is presented herein. To illustrate the process we have included two examples of current clinical protocols utilized by our division.

Algorithms↗

PubMed2006

Prospective evaluation of an extubation protocol in a trauma intensive care unit population.

Little data exists regarding extubation protocols in critically injured trauma patients. The objective of the current study was to prospectively examine the impact of implementing an extubation protocol on the outcomes of ventilated trauma patients in a surgical intensive care unit (STICU). Trauma patients admitted to the STICU over a 15-month period at a Level 1 trauma center were prospectively evaluated. The total period was divided into an education and institution period (April 2002-November 2003) and an evaluation period (December 2003-July 2003). Patient demographics, hospital course, complications, and outcomes from period I were compared with those obtained during period II. From April 8, 2002 through July 5, 2003, 69 patients intubated for greater than 24 hours were included in our analysis. Thirty-three were treated during period I and 36 were treated during period II. Both groups were well matched in terms of age, sex, Injury Severity Score, and chest Abbreviated Injury Score. Ventilation days significantly decreased from a mean of 16.3 to 8.2 days (P = 0.04). ICU length of stay also decreased, nearly meeting significance. A rigorously enforced extubation protocol significantly decreased ventilator days in STICU patients. Continued education of health care providers is key to the success of the protocol.

Accidents, Traffic↗