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PubMed1999

British Association of Surgical Oncology Guidelines. The management of metastatic bone disease in the United Kingdom. The Breast Specialty Group of the British Association of Surgical Oncology.

Bone metastases can present to a number of different specialties and their successful management requires a coordinated approach with good liaison between the specialists. Patients who respond to systemic therapy for their metastases have a good chance of being alive at 3 years, and 20% will be alive at 5 years. This means that it is worth palliating these patients properly. With this in mind, the intention of this document is to try and improve the process of care for women with metastatic bone disease from breast cancer. These guidelines consider all aspects of care from diagnosis to assessment of response to treatment, and describe the Quality Objectives that should be addressed at each stage. The level of available evidence is indicated throughout the document where possible. In considering diagnosis, the guidelines emphasize the value of having a dedicated orthopaedic surgeon specifically linked to each Cancer Unit. The attachment of a dedicated orthopaedic surgeon will ensure that mechanical problems are correctly identified, and that actual or imminent fracture is correctly managed. The latter is particularly important as the management of pathological fractures is not the same as that of traumatic fractures. The orthopaedic surgeon should also act as the liaison between his/her own Unit and the tertiary spinal or neurosurgical centres as necessary. In addition, empowering the radiologist means that the diagnostic process can be accelerated and refined. The place of different investigations in diagnosis, including tumour markers, is discussed. The guidelines emphasize the need for a definitive diagnosis before treatment in the (rare) case of a solitary metastasis. The treatment section discusses orthopaedic management, radiotherapy and systemic treatments (endocrine therapy, chemotherapy and bisphosphonates). The guidelines emphasize the emergency nature of spinal cord compression, describing the need for fast access to assessment and for good liaison between specialists. It is essential that these are available and widely publicized to ensure effective management. The role of radiotherapy in both local pain relief and spinal cord compression is discussed, and various techniques are described. Endocrine therapy and chemotherapy are discussed in relation to the disease-free interval, performance status, extent and site of metastatic disease, and oestrogen receptor status. Specific chemotherapy regimes are not discussed as these are subject to change and local protocols should be followed. The increasing evidence behind the role of bisphosphonates is reviewed. With many unanswered questions about the long-term use of this group of drugs, the guidelines offer a scoring system for deciding which patients might benefit most from long-term bisphosphonate therapy. The guidelines describe the possible ways of assessing response to treatment and the difficulties that may be encountered, including a discussion of the role of tumour markers in assessment of response. A final section looks at palliative care principles in bone pain management, acknowledging the need for continuation of good care throughout the patient's journey, from diagnosis onwards. We very much hope these guidelines will stimulate individuals and institutions to improve the process of delivering care to this group of patients.

Algorithms↗

PubMed1999

An object-oriented framework for the development of computer-based guideline implementations.

Clinical practice guidelines provide a means of directing medical care towards clinically appropriate and cost-effective interventions. A direct relationship exists between the integration of a guideline into clinical workflow and the effectiveness of the guideline in influencing clinicians' behavior. Computer-based guideline implementations, used at the point-of-care, accomplish this integration. Employing object-oriented technologies, we propose a framework of reusable components for the development of guideline implementation systems. We have identified eight information management services that are common to such systems. Our framework integrates these services and their respective reusable components into clinical workflow to promote the development of comprehensive guideline implementation systems, which should ultimately enhance guideline compliance and the overall quality of care.

Guideline Adherence↗

PubMed2000

Acute childhood idiopathic thrombocytopenic purpura: AIEOP consensus guidelines for diagnosis and treatment. Associazione Italiana di Ematologia e Oncologia Pediatrica.

BACKGROUND AND OBJECTIVE: A recent evaluation carried out by the Associazione Italiana di Ematologia e Oncologia Pediatrica (AIEOP) about practice management of acute childhood idiopathic thrombocytopenic purpura (ITP) revealed a remarkable difference of behaviors among the different AIEOP centers. A need for common practice guidelines for this frequent illness arose from this observation. Our aim was to make the diagnosis and treatment of childhood ITP uniform. In the future we will evaluate the influence of these guidelines on practice behaviors. DATA SOURCES AND METHODS: Our main reference was the 1996 document produced by the American Society of Hematology (ASH). Their recommendations were updated with information from literature searched for in the MEDLINE database (June 1996-October 1998); search terms included: thrombocytopenia, ITP, diagnosis, therapy, children. The computerized search retrieved 83 articles. DATA EXTRACTION: the scientific validity of the literature was evaluated by a panel of members using published guidelines. The strength of the evidence was assessed using level of evidence criteria. Only data from level I and level II studies were taken in account. Only one study out of the 83 retrieved articles met these selection criteria and it was considered in addition to the 11 out of 581 articles selected in the ASH ITP guidelines. This preliminary work pointed out each issue about ITP not addressed by clinical studies and all participants in a Consensus Conference expressed their opinion about these issues. RESULTS: Diagnosis is essentially based on history, physical examination, a complete blood count and an examination of the peripheral blood smear. Treatment is recommended taking into account the clinical picture and number of platelets. The main difference between these guidelines and those from ASH are: AIEOP guidelines rely on the opinion of the members of the consensus conference, ASH ones on a panel of experts; therapeutic options include only products available in Italy; the indications to treatment rely more on clinical picture than on platelet number. INTERPRETATION AND CONCLUSIONS: These are explicitly developed, evidence-based practice guidelines to assist Italian pediatricians in making decisions about diagnosis and appropriate health care for patients with acute childhood ITP.

Acute Disease↗

PubMed2000

Management of high blood cholesterol levels in Nova Scotian adults: comparison with the NCEP II and European clinical practice guidelines.

OBJECTIVE: To compare the prevalence of dietary and drug treatment for high blood cholesterol levels with indication for treatment according to the National Cholesterol Education Program (NCEP) II and European clinical practice guidelines. STUDY DESIGN: A population-based, cross-sectional study. PATIENTS AND METHODS: Data were from the 1995 Nova Scotia Health Survey. Patients were 2078 respondents aged 20 to 74 years who provided blood samples. Based on cardiovascular risk factors, respondents were compared with guidelines to determine eligibility for dietary and antilipemic drug therapy. RESULTS: According to the NCEP II and European guidelines, 21% and 13%, respectively, of the population were estimated to be dietary therapy candidates and 12% and 4%, respectively, were estimated to be candidates for antilipemic drug therapy. Less than half of the dietary therapy candidates, according to either guideline, reported being diagnosed, and only about half of those diagnosed reported having received dietary therapy. Overall, 6% to 15% of the NCEP II drug therapy candidates and 12% to 37% of the European drug therapy candidates were estimated to be receiving antilipemic drugs. Only about 45% of the NCEP II and 60% of the European drug therapy candidates reported being diagnosed as having high blood cholesterol levels, and only about 50% of the NCEP II- and 60% of the European-diagnosed drug therapy candidates reported having received dietary therapy. The estimated prevalence of antilipemic drug therapy among diagnosed drug therapy candidates was 12% to 29% for the NCEP II and 12% to 52% for the European guidelines. CONCLUSIONS: Dietary therapy and antilipemic drug therapy were underused relative to the NCEP II and European guidelines as a result of underdiagnosis and low use of treatment after diagnosis. Large differences in the recommendations of the 2 guidelines, however, show lack of consensus as to who should be treated and point to the need for additional research on this issue.

Adult↗

PubMed2002

Making, disseminating and using clinical guidelines.

Clinical guidelines are statements designed to help physicians make decisions about appropriate health care for specific circumstances. The constant rise in the number of published guidelines has been accelerated by the need of healthcare organizations to integrate evidence from clinical research with rational health policy, with the prospect of improving the quality and reducing the costs of health care at a local level. The best guidelines are developed from a systematic examination and appraisal of good evidence from well conducted trials, supported by appropriate clinical expertise, and leading to unambiguous recommendations. Great care needs to be taken both to maximize the validity of guidelines and to ensure their use within clinical practice. Moreover, the evidence on which clinical guidelines are based can change with time and therefore they should be reviewed regularly. The critical approaches to making high-quality guidelines, the value of implementation strategies, and how healthcare organizations and individual physicians can use medical guidelines to enhance clinical effectiveness will be discussed.

Delivery of Health Care↗

PubMed2002

[Dutch Institute for Healthcare Improvement guideline, "Treatment of breast cancer"].

The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.

Breast Neoplasms↗

PubMed2003

Characteristics of effective clinical guidelines for general practice.

BACKGROUND: The use of clinical guidelines in general practice is often limited. Research on barriers to guideline adherence usually focuses on attitudinal factors. Factors linked to the guideline itself are much less studied. AIM: To identify characteristics of effective clinical guidelines for general practice, and to explore whether these differ between therapeutic and diagnostic recommendations. DESIGN OF STUDY: Analysis of performance data from an audit study of 200 general practitioners (GPs) in The Netherlands conducted in 1997. SETTING: Panel of 12 GPs in The Netherlands who were familiar with guideline methodology. METHOD: A set of 12 attributes, including six potential facilitators and six potential barriers to guideline use, was formulated. The panel assessed the presence of these attributes in 96 guideline recommendations formulated by the Dutch College of General Practitioners. The attributes of recommendations with high compliance rates (70% to 100%) were compared with those with low compliance rates (0% to 60%). RESULTS: Recommendations with high compliance rates were to a lesser extent those requiring new skills (7% compared with 22% in recommendations with low compliance rates), were less often part of a complex decision tree (12% versus 25%), were more compatible with existing norms and values in practice (87% versus 76%), and more often supported with evidence (47% versus 31%). For diagnostic recommendations, the ease of applying them and the potential (negative) reactions of patients were more relevant than for therapeutic recommendations. CONCLUSION: To bridge the gap between research and practice, the evidence as well as the applicability should be considered when formulating recommendations. If the recommendations are not compatible with existing norms and values, not easy to follow or require new knowledge and skills, appropriate implementation strategies should be designed to ensure change in daily practice.

Family Practice↗

PubMed2003

[German Society for General Medicine--guidelines for urinary incontinence: content and development].

In this article, the authors of the "General Practitioners' Guideline to the Diagnosis and Treatment of Urinary Incontinence" describe the historical development of this evidence-based GPs' guideline for the management of urinary incontinence. The guideline's history is focused around the following points: 1. reasons for choosing the subject matter, 2. material and personnel expenses of the development process, 3. specific considerations regarding recommendations that will be applied to the primary care setting. The whole guideline project was based on the hypothesis that developing and implementing a clinical guideline for general practitioners in Germany would lead to better detection and treatment of cases of urinary incontinence. Hopefully, the guideline will contribute to a better quality of life of the persons affected and to a reduced number of "silent sufferers". Specifically, the targets to be addressed include the following: identifying and providing treatment to previously undiscovered sufferers of urinary incontinence implementing a universal standard of scientifically approved diagnostic strategies in family physician's offices enhancing the therapeutic options available to patients suffering from urinary incontinence in the community aiding primary care physicians with the diagnosis and treatment of people with urinary incontinence improving the interprofessional relationships with other carers in the field of urinary incontinence. The authors wish to thank the German Cochrane Centre and the Deutsche Krankenversicherung for organising the Cochrane Prize and thus promoting guideline development.

Germany↗

PubMed1992

Proposal for establishing structure and process in the development of implicit chiropractic standards of care and practice guidelines.

With the advent of health care's "era of accountability", the chiropractic profession is now faced with generating implicit standards and guidelines for care or having it done for us by outside agencies. Already we see chiropractic groups in individual states and provinces being pressured into naive efforts of guideline development. Current knowledge and experience are available through recent health care literature that clearly defines the structure and process of guideline development and offers suggestions on how to measure outcomes of those processes. In addition, the United States Congress has directed a new federal agency to oversee this activity and monitor outcomes of quality improvement programs. The time has come for the chiropractic profession to define its exact role in health care delivery and develop implicit standards of care and practice guidelines. This sentinel effort should be managed by a commissioned body of empaneled experts that generally represent the academic and clinical chiropractic profession. A protocol for selection of these panelists and the panel chairperson needs to be developed and memorialized. Appropriate methodology (with definitions) needs to be developed for the process of standards/guideline development. Adherence to the accepted structure and process of guideline development will ensure the continuity of this dynamic process in the coming generations. This proposal offers a preliminary definition of the structure and process, including a "seed" policy statement and decision flow chart, specific to guideline development. Once the structure and process of guideline development for chiropractic are defined, the profession can then present this product to federal and state agencies, private sector health care purchasers, patient advocacy groups and other stakeholders of chiropractic care.(ABSTRACT TRUNCATED AT 250 WORDS)

Chiropractic↗

PubMed2003

Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment.

BACKGROUND: Many older patients with fractures are not managed in accordance with evidence-based clinical guidelines for osteoporosis. Guidelines recommend that these patients receive treatment for clinically apparent osteoporosis or have bone mineral density measurements followed by treatment when appropriate. This cohort study was conducted to further characterize the gap between guidelines and actual practice with regard to bone mineral density measurement and treatment of older women after a fracture. Our purpose was to aid in the design of more effective future interventions. METHODS: We identified female members of a not-for-profit group-model health maintenance organization who were fifty years of age or older and who had a diagnosis of a new fracture as defined in the study. We used administrative databases and the clinical electronic medical records to obtain data on demographics, diagnoses, drugs dispensed by the pharmacy, and the measurement of bone mineral density. RESULTS: The study population included 3812 women with an average age of 71.3 years. Fewer than 12% of the women had a diagnosis of osteoporosis prior to the index fracture; 10.7% had an increased risk for secondary osteoporosis and 38.8%, for falls because of a diagnosis or medication. It was found that 46.4% of the study population had been managed as specified by clinical guidelines. The patients who had been managed as specified by the guidelines were younger and less likely to have the risk factor of a weight of <127 lb (58 kg), a hip fracture, or a wrist fracture. They were also more likely to be taking steroids on a chronic basis and to have had a vertebral fracture. The percentage of women who had measurement of bone mineral density increased during the study period, from 1.3% in 1998 to 10.2% in 2001. Of the patients receiving treatment for osteoporosis, 73.6% adhered to the treatment regimen. CONCLUSIONS: Adherence to guidelines for evaluation and treatment for osteoporosis after a patient sustained a fracture did not improve between 1998 and 2001 despite the promulgation of evidence-based guidelines. Methods to enhance education and facilitate processes of care will be necessary to reduce this gap. It may be fruitful to target high-risk subgroups for tailored interventions for prevention of refracture.

Absorptiometry, Photon↗

PubMedDate not supplied

International standards and guidelines on education and training for the multi-disciplinary health response to major events that threaten the health status of a community.

UNLABELLED: The 13th World Congress on Disaster and Emergency Medicine, convened in Melbourne, Australia in May 2003, requested the World Association for Disaster and Emergency Medicine (WADEM) to lead the development of "International Standards and Guidelines on Education and Training for "Disaster Medicine". This Paper has been developed by a Working Group of the WADEM Education Committee ("the Working Group") in response to that request from the international "Disaster Medicine" and emergency health community. The main focus of the Working Group is to develop standards and guidelines for education and training in the multi-disciplinary health response to major events that threaten the health status of a community. The contemporary view is that of a multi-disciplinary health response to major events which threaten the health status of a community, including the prevention and mitigation of future events, and taking account of the broader context in which these events occur. It is the vision of the Working Group that evidence-based standards and guidelines for education and training must be developed in a broad sense, for all members of the healthcare community. Rather than purely describing isolated performance indicators, the Working Group agreed that priority be given to explaining the general approach, presenting the conceptual framework, clarifying important principles, and describing the educational needs and training requirements for situations for which there exist a major threat to the health status of a community. It is not the intent to produce an updated educational curriculum for special courses in "Disaster Medicine" by listing levels of theoretical knowledge and clinical skills required for medical doctors, nurses, and paramedics. Nor, does the Working Group think it is useful to repeat requirements and learning outcomes that are part of the normal basic education and training for the various health professionals. The purpose of this Issues Paper is to present an initial summary of current issues relating to an international perspective of "Disaster Medicine" education and training. This summary has been prepared following discussions within the Working Group of the WADEM Education Committee. The paper aims to stimulate debate and form the basis of further of discussion at an international meeting scheduled to be held in Brussels (Belgium) on 29-31 October 2004. The Working Group has structured this Issues Paper into five parts and has identified several key issues for discussion. Part 1: Understanding the contemporary interpretation of the multi-disciplinary health response to major events that threaten the health status of a community. Issue 1: Definitions and terminology in "Disaster Medicine"; Issue 2: Getting to grips with the contemporary concepts and international trends in 'Disaster Medicine"; and, Issue 3: Valuing personal attributes in "Disaster Medicine" practitioners. Part 2: Developing an underlying scientific framework for linking theory to practice in "Disaster Medicine". Issue 4: Creating a scientific framework(s) for "Disaster Medicine". Part 3: Defining a conceptual framework and general principals to develop "International Standards and Guidelines on Education and Training for the Multi-disciplinary Health Response to Major Events that Threaten the Health Status of a Community". Issue 5.: Where are we now? Getting to grips with the contemporary concepts and international trends in "Disaster Medicine" education and training. Issue 6: Where do we want to get to? Identifying contemporary, evidence-based education and training standards and guidelines for 'Disaster Medicine" education and training programs. Issue 7: How do we get there? Overcoming barriers to introducing the International Standards and Guidelines. Part 4: Maintaining the momentum--improving international collaboration. Issue 8: Exploring the feasibility of an ongoing, international, collaborative network of "Centres of Excellence" in "Disaster Medicine" research and/or education. Part 5: Additional input. Issue 9: What other issues would you like to bring to the attention of the Working Group? CONCLUSIONS: The results of the consultation will lead to the development of international standards and guidelines that will be presented and consensus sought during the 14th World Congress on Disaster and Emergency Medicine (WCDEM-14) to be convened in Edinburgh in May, 2005.

Civil Defense↗

PubMed2005

[Guidelines in general practice--are they read and are they used?].

BACKGROUND: Many guidelines are not developed from systematic models and are not based on high-quality evidence. The existence of a guideline does not in itself lead to changes in practice and many guidelines are not used once they have been issued. MATERIAL AND METHODS: A questionnaire on continuing education and the use of guidelines was sent to 1500 general practitioners (GP) and GP assistants in 1321 general practices in Norway. 857 GPs and 948 GP assistants returned the questionnaire. RESULTS: There was a large variation in the extent to which guidelines were known and used. Many GPs and GP assistants had little knowledge of guidelines published in the Journal of the Norwegian Medical Association or by the Norwegian Medicines Agency, the Norwegian Board of Health or the Norwegian Centre for Health Technology Assessment. There were exceptions: 52% of GPs used the Norwegian College of General Practitioners' treatment programme for diabetes and 77% of GP assistants used the Norwegian quality assurance programme for laboratory services in primary care. INTERPRETATION: Guidelines should be based on the best available evidence but this in itself is not enough to ensure that they are adhered to. Effective strategies for implementation are also important.

Education, Medical, Continuing↗

PubMed2005

Impact of the introduction of a guideline on the targeted detection of hereditary haemochromatosis.

BACKGROUND: In 1998 a clinical guideline for the targeted, accurate and early detection and treatment of HFE-related hereditary haemochromatosis (HH), which comprises a test for the causative HFE-gene mutations, was introduced in our outpatient department. METHODS: The impact of this guideline was evaluated retrospectively. Data were acquired from medical records of patients with discharge diagnosis codes suggestive of HH (n=878 patients), obtained from a period before (n=422) and after guideline introduction (n=456). RESULTS: Combined measurements of serum transferrin saturation and serum ferritin rose from 12.2% (n=53) to 29.5% (n=138, p<0.001), leaving 70% of the patients eligible for HH not tested for iron parameters. The HFE-gene mutation detection test was correctly used in II (40.7%) of 27 tested patients and improperly interpreted in six (22.2%) of these 27 patients. Five new HH patients were diagnosed before and 13 after introduction. Seven of these 13 patients appeared to be incorrectly diagnosed, due to misinterpretation of laboratory results. Diagnostic costs of case detection for each accurately diagnosed patient were euro 2380 before and euro 2600 after introduction of the guideline. CONCLUSION: Evaluation of the introduction of a practical guideline for targeted HH detection reveals a low compliance with the guideline, resulting in both a small percentage of patients tested for HH and overdiagnosis of HH. Therefore, the introduction of the guideline should be combined with a more appropriate implementation strategy which includes education on its most critical points, i.e. the indication and interpretation of the iron parameters and the HFE genotype.

Biopsy↗

PubMed2006

Effects of the tobacco use cessation automated clinical practice guideline.

OBJECTIVE: To evaluate the effects of the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) (a variation of the US Department of Health and Human Services Clinical Practice Guideline on Treating Tobacco Use and Dependence) on guideline adherence in a multisite health system. STUDY DESIGN: The study used a pre-post cross-sectional design. Paneled patients were enrolled from 6 clinics, including 2 control clinics (arm 1), 2 control clinics that received a check-in screen only (the check-in screen provided a simplified method for entering patient vital signs into the electronic medical record) (arm 2), and 2 clinics that received the TUC intervention (arm 3). METHODS: Baseline data on physician compliance with the 5 As (ask, assess, advise, assist, and arrange) at the last office visit were collected via telephone surveys from patients in the 3 study arms. The TUC-ACPG was then introduced in the TUC intervention clinics as part of the existing electronic medical record. Approximately 2 weeks after the TUC intervention, postimplementation data were collected via telephone survey. RESULTS: In the TUC intervention arm, postimplementation adherence rates increased relative to baseline for all 5 points of the guideline, with the largest increases seen in the assess and arrange guideline points. Controlling for factors such as age, race, and relevant comorbidities, logistic regression analysis indicated that the time (preimplementation vs postimplementation)-x-TUC intervention arm interaction demonstrated a statistically significant increase in the assess guideline point. CONCLUSION: Although baseline adherence rates were already high, the introduction of the TUC-ACPG led to further increases in guideline adherence.

Adolescent↗

PubMed1991

Guidelines for medical technology in critical care. Technology Subcommittee of the Working Group on Critical Care, Ontario Ministry of Health.

OBJECTIVE: To examine the current status of technology in critical care medicine and to present guidelines for technologies commonly used in Ontario critical care units. DATA SOURCES: A computerized search of the medical literature, interviews with relevant people and a review of existing guidelines or standards were conducted. STUDY SELECTION: Nonrandomized trials and retrospective reviews were included because of a paucity of prospective randomized controlled trials. DATA EXTRACTION: Technologies were assessed by individual committee members. The validity of the technologies was compared with accepted standards when available. All published clinical data were used to assess efficacy. DATA SYNTHESIS: After review of the data, discussion papers on ventilation, and electrocardiographic, hemodynamic and intracranial pressure monitoring were written by committee members and then reviewed by the subcommittee as a whole. For each technology an attempt was made to match need with the patient classifications of the Working Group on Critical Care. Critical care guidelines were then developed through the use of the nominal group and Delphi consensus-gathering techniques. The guidelines were reviewed by external experts. CONCLUSIONS: These guidelines should help in assessing quality assurance and the resources necessary for critical care. Also, they should enable health care providers and hospital administrators to make better decisions when acquiring critical care technology. Since the guidelines represent the current state of knowledge there must be a continuing assessment of the technology and review of the guidelines.

Critical Care↗

PubMed1997

Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Headache Society.

OBJECTIVE: To provide physicians and allied health care professionals with guidelines for the diagnosis and management of migraine in clinical practice. OPTIONS: The full range and quality of diagnostic and therapeutic methods available for the management of migraine. OUTCOMES: Improvement in the diagnosis and treatment of migraine, which will lead to a reduction in suffering, increased productivity and decreased economic burden. EVIDENCE AND VALUES: The creation of the guidelines followed a needs assessment by members of the Canadian Headache Society and included a statement of objectives; development of guidelines by multidisciplinary working groups using information from literature reviews and other resources; comparison of alternative clinical pathways and description of how published data were analysed; definition of the level of evidence for data in each case; evaluation and revision of the guidelines at a consensus conference held in Ottawa on Oct. 27-29, 1995; redrafting and insertion of tables showing key variables and data from various studies and tables of data with recommendations; and reassessment by all conference participants. BENEFITS, HARMS AND COSTS: Accuracy in diagnosis is a major factor in improving therapeutic effectiveness. Improvement in the precise diagnosis of migraine, coupled with a rational plan for the treatment of acute attacks and for prophylactic therapy, is likely to lead to substantial benefits in both human and economic terms. RECOMMENDATIONS: The diagnosis of migraine can be improved by using modified criteria of the International Headache Society as well as a semistructured patient interview technique. Appropriate treatment of symptoms should take into account the severity of the migraine attack, since most patients will have attacks of differing severity and can learn to use medication appropriate for each attack. When headaches are frequent or particularly severe, prophylactic therapy should be considered. Both the avoidance of migraine trigger factors and the application of nonpharmacological therapies play important roles in overall migraine management and will be addressed at a later date. VALIDATION: The guidelines are based on consensus of Canadian experts in neurology, emergency medicine, psychiatry, psychology, family medicine and pharmacology, and consumers. Previous guidelines did not exist. Field testing of the guidelines is in progress.

Adrenergic beta-Antagonists↗

PubMed1997

Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee.

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. These guidelines are also approved by the governing boards of American College of Gastroenterology and Practice Parameters Committee. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.

Anti-Bacterial Agents↗

PubMed1997

Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology.

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by the interpretation and collation of scientifically valid research, derived from an extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. These guidelines are also approved by the governing boards of the American Gastroenterology Association and the American Society of Gastrointestinal Endoscopy. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the Committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.

Acute Disease↗