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NHS Greater Glasgow and Clyde

- Clinical Librarian -

NHSGGC Guidelines NewsletterDecember 2006

Welcome to the NHS GG&C Guidelines Newsletter. The newsletter is intended as an information tool to help you keep up to date with developments in your area of clinical expertise and interest. It is not in any way an expression of organisational policy. The inclusion of a guideline in this newsletter does not imply that it is used, or should be implemented, within NHS Greater Glasgow and Clyde. Any views expressed in guidelines quoted in the newsletter will have to be subjected to the scrutiny of your own clinical judgement. You are, however, welcome to use the guideline newsletter to inform your practice or service development.

This newsletter covers national and international guidelines that have either been published or added to specialist databases (such as Medline or CINAHL) in the previous month. It is divided into three sections: one for clinical guidelines from the UK, one for clinical guidelines from international bodies and one for publications on guideline implementation. Within the two clinical sections, there are sub-categories to make it easier for you to find the guidelines that might be relevant to your practice.

Where available, the newsletter includes abstracts and links to online full-text versions or executive summaries of the guidelines.

Contents

A. UK Guidelines ……………………………………………………………………………………………………. p.2

1. Primary Care …………………………………………………………………………………………. p. 22. Cancer Care/Palliative Care ………………………………………………………………………………. p. 23. Mental Health and Learning Disabilities ……………………………………………………………………. p. 34. Dentistry …………………………………………………………………………………………. p. 35. Sexual Health, BBV and related Topics ……………………………………………………………………. p. 36. Child Health …………………………………………………………………………………………. p. 3

B. International Guidelines …………………………………………………………………………………………. p. 4

1. Primary Care …………………………………………………………………………………………. p. 42. Cancer Care/Palliative Care ……………………………………………………………………. p. 133. Mental Health and Learning Disabilities ……………………………………………………………………. p. 144. Dentistry …………………………………………………………………………………………. p. 155. Sexual Health, BBV and related Topics ……………………………………………………………………. p. 166. Child Health …………………………………………………………………………………………. p. 18

C. Guidelines Implementation ………………………………………………………………………………………. p. 20

If you would like to obtain full text versions of any of the guidelines listed in the newsletter, please refer to the NHSScotland e-Library where you will find most of the guidelines in full text. The e-Library is accessible to all NHSScotland staff at http://www.elib.scot.nhs.uk. Full text access requires an ATHENS password, which can be obtained online from the e-Library website. For those guidelines that are not available online, please fill in and sign the document request form that is included with the newsletter and send it to the Maria Henderson Library, Gartnavel Royal Hospital. Phone: 0141-211 3913.

Carsten Mandt, Clinical Librarian, NHS GG&C, West House, CGSU Office, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: [email protected].

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mailto:[email protected]

http://www.elib.scot.nhs.uk/

A. UK Guidelines

Primary Care

Hay CR, Brown S, Collins PW, Keeling DM, Liesner R. The diagnosis and management of factor VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors Organisation. British Journal of Haematology 133(6) 2006: 591-605.

The revised UKHCDO factor (F) VIII/IX Inhibitor Guidelines (2000) are presented. A schema is proposed for inhibitor surveillance, which varies according to the severity of the haemophilia and the treatment type and regimen used. The methodological and pharmacokinetic approach to inhibitor surveillance in congenital haemophilia has been updated. Factor VIII/IX genotyping of patients is recommended to identify those at increased risk. All patients who develop an inhibitor should be considered for immune tolerance induction (ITI). The decision to attempt ITI for FIX inhibitors must be carefully weighed against the relatively high risk of reactions and the nephrotic syndrome and the relatively low response rate observed in this group. The start of ITI should be deferred until the inhibitor has declined below 10 Bethesda Units/ml, where possible. ITI should continue, even in resistant patients, where it is well tolerated and so long as there is a convincing downward trend in the inhibitor titre. The choice of treatment for bleeding in inhibitor patients is dictated by the severity of the bleed, the current inhibitor titre, the previous anamnestic response to FVIII/IX, the previous clinical response and the side-effect profile of the agents available. We have reviewed novel dose-regimens and modes of administration of FEIBA (factor VIII inhibitor bypassing activity) and recombinant activated FVII (rVIIa) and the extent to which these agents may be used for prophylaxis and surgery. Bleeding in acquired haemophilia is usually treated with FEIBA or rVIIa. Immunosuppressive therapy should be initiated at the time of diagnosis with Prednisolone 1 mg/kg/d +/- cyclophosphamide. In the absence of a response to these agents within 6 weeks, second-line therapy with Rituximab, Ciclosporin A, or other multiple-modality regimens may be considered.

Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology 45(9) 2006: 1167-1169.

Weston V, Coakley G, The British Society for Rheumatology Standards and Guidelines, Audit Working Group, British Society for Antimicrobial Chemotherapy, British Orthopaedic Association, et al. Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis. Journal of Antimicrobial Chemotherapy 58(3) 2006: 492-3.

The British Society for Rheumatology (BSR) Standards, Guidelines and Audit Working Group, in conjunction with the British Society for Antimicrobial Chemotherapy, British Orthopaedic Association, Royal College of General Practitioners and British Health Professionals in Rheumatology, has produced an evidence-based guideline for the management of the hot swollen joint with particular focus on the septic joint. The aim of the guideline is to help accurate diagnosis and appropriate treatment when a joint is hot because of sepsis, while also ensuring that other causes such as crystal arthritis are recognized and not over-treated.

Back to the Contents page

Cancer Care/Palliative Care

Milligan DW, Grimwade D, Cullis JO, Bond L, Swirsky D, Craddock C, et al. Guidelines on the management of acute myeloid leukaemia in adults. British Journal of Haematology 135(4) 2006: 450-474.


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National Institute for Cinical and Healthcare Excellence (NICE). Hormonal therapies for the adjuvant treatment of early oestrogen-receptor-positive breast cancer. London: NICE, 2006. URL: http://www.nice.org.uk/guidance/TA112 [last accessed: 06.12.2006].


Mental Health and Learning Disabilities

National Institute for Cinical and Healthcare Excellence (NICE). Dementia: Supporting people with dementia and their carers in health and social care. London: NICE, 2006. URL: http://www.nice.org.uk/guidance/cg42 [last accessed: 06.12.2006].

National Institute for Cinical and Healthcare Excellence (NICE). Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer's disease. London: NICE, 2006. URL: http://www.nice.org.uk/guidance/TA111 [last accessed: 06.12.2006].


Dentistry

No relevant new guidance was published this month.


Sexual Health, BBV and related Topics

Gazzard B, Bernard EJ, Boffito M, Churchill D, Edwards S, Fisher M, et al. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2006) . HIV Medicine 7(8) 2006: 487-503.

Nandwani R, Clinical Effectiveness Group of the British Association for Sexual Health and HIV. 2006 United Kingdom national guideline on the sexual health of people with HIV: sexually transmitted infections. International Journal of STD & AIDS 17(9) 2006: 594-606.

Rogstad KE, Palfreeman A, Rooney G, Hart GJ, Lowbury R, Mortimer P, et al. UK national guidelines on HIV testing 2006. International Journal of STD & AIDS 17(10) 2006: 668-676.


Child Health

Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. 2006. URL: http://www.sign.ac.uk/pdf/sign91.pdf [last accessed: 06.12.2006].

If you have any comments on the above Guidelines, or would like a copy of any SIGN Guidelines, please contact Grace Watson on 0141 211 3916 or email [email protected].



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http://www.sign.ac.uk/pdf/sign91.pdf

http://www.nice.org.uk/guidance/TA111

http://www.nice.org.uk/guidance/cg42

http://www.nice.org.uk/guidance/TA112

B. International Guidelines

Primary CareAnderson CAM, Miller IE. Dietary Recommendations for Obese Patients with Chronic Kidney Disease. Advances in Chronic Kidney Disease 13(4) 2006: 394-402.

For optimal management of chronic kidney disease (CKD), dietary modification should be an integral part of patient care. Dietary considerations for obese patients with CKD are numerous and complicated and involve modification of intake of calories, protein, fat, phosphorus, and electrolytes. General principles for dietary management of obese patients include (1) ensuring adequate monitoring of nutritional status through assessment of diet, nutrition-related laboratory parameters, and anthropometrics; (2) creation of an individualized diet plan that meets clinical guidelines and has favorable effects on obesity-related conditions such as blood pressure and lipids; (3) careful attention to patients' food choices, portion size, and food-preparation methods; (4) recommending adjustment of overall energy intake to promote weight loss, yet maintain good nutritional status; and (5) modification of diet as the patient's nutritional status changes and CKD progresses. The basic objectives of dietary modification are to lighten the excretory load of products of metabolism and to help the kidney maintain normal equilibrium of the body's internal environment. Dietary modifications must be individualized and appropriate to the stage of CKD. This review describes dietary factors important in optimizing nutritional status of obese patients with CKD. Additionally, current clinical practice guidelines and strategies for meeting them are discussed.

Andros G, Armstrong DG, Attinger CE, Boulton AJM, Frykberg RG, Joseph WS, et al. Consensus statement on negative pressure wound therapy (V.A.C. therapy) for the management of diabetic foot wounds. Wounds: A Compendium of Clinical Research and Practice. (Supplement) 2006: 1-32.

In 2004, a multidisciplinary expert panel convened at the Tucson Expert Consensus Conference (TECC) to determine appropriate use of negative pressure wound therapy as delivered by a Vacuum Assisted Closure device (V.A.C.(R) Therapy, KCI, San Antonio, Tex) in the treatment of diabetic foot wounds. These guidelines were updated by a second multidisciplinary expert panel at a consensus conference on the use of V.A.C.(R) Therapy, held in February 2006, in Miami, Florida. This updated version of the guidelines summarizes current clinical evidence, provides practical guidance, offers best practices to clinicians treating diabetic foot wounds, and helps direct future research., The Miami consensus panel discussed the following 12 key questions regarding V.A.C.(R) Therapy: 1) How long should V.A.C.(R) Therapy be used in the treatment of a diabetic foot wound? 2) Should V.A.C.(R) Therapy be applied without debriding the wound? 3) How should the patient using V.A.C.(R) Therapy be evaluated on an outpatient basis? 4) When should V.A.C.(R) Therapy be applied following revascularization? 5) When should V.A.C.(R) Therapy be applied after incision, drainage, and debridement of infection? 6) Should V.A.C.(R) Therapy be applied over an active soft tissue infection? 7) How should V.A.C.(R) Therapy be used in patients with osteomyelitis? 8) How should noncompliance to V.A.C.(R) Therapy be defined? 9) How should V.A.C.(R) Therapy be used in combination with other modalities? 10) Should small, superficial wounds be considered for V.A.C.(R) Therapy? 11) How should success in the use of V.A.C.(R) Therapy be defined? 12) How can one combine effective offloading and V.A.C.(R) Therapy?

Anonymous. Guideline for semi-rush immunotherapy in wasp and bee allergy. Nederlands Tijdschrift voor Dermatologie & Venereologie 16(7) 2006: 298-300.

Anonymous. Standard of the Dutch College of General Practitioners on urinary incontinence: First revision. Huisarts en Wetenschap 49(10) 2006: 501-510.

Anonymous. Diabetes and coronary heart disease: New guidelines for treatment and prevention. MMW Fortschritte der Medizin 148(41) 2006: 10-16.

Banks PA, Freeman ML, Fass R, Baroni DS, Mutlu EA, Bernstein DE, et al. Practice guidelines in acute pancreatitis. American Journal of Gastroenterology 101(10) 2006: 2379-2400.

The diagnosis of acute pancreatitis requires two of the following three features: 1) characteristic abdominal pain, 2) serum amylase and/or lipase >=3 times the upper limit of normal, and 3)


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characteristic findings of acute pancreatitis on CT scan. Risk factors of severity of acute pancreatitis at admission include older age, obesity, and organ failure. Tests at admission that are also helpful in distinguishing mild from severe acute pancreatitis include APACHE-II score >=8 and serum hematocrit (a value <44 strongly suggests mild acute pancreatitis). An APACHE-II score that continues to increase for the first 48 h strongly suggests the development of severe acute pancreatitis. A CRP >150 mg/L within the first 72 h strongly correlates with the presence of pancreatic necrosis. The two most important markers of severity in acute pancreatitis are organ failure (particularly multisystem organ failure) and pancreatic necrosis. Contrast-enhanced CT scan is the best available test to distinguish interstitial from necrotizing pancreatitis, particularly after 2-3 days of illness. Mortality of sustained multisystem organ failure in association with necrotizing pancreatitis is generally >36%. Supportive care includes vigorous fluid resuscitation that can be monitored in a variety of ways including a progressive decrease in serum hematocrit at 12 and 24 h. Supplemental oxygen should be administered during the first 24-48 h, bedside oxygen saturation monitored at frequent intervals, and blood gases obtained when clinically indicated, particularly when oxygen saturation is <=95%. Transfer to an intensive care unit is recommended if there is sustained organ failure or if there are other indications that the pancreatitis is severe including oliguria, persistent tachycardia, and labored respiration. Patients who are unlikely to resume oral nutrition within 5 days because of sustained organ failure or other indications require nutritional support. Nutiritional support can be provided by TPN or by enteral feeding. There appear to be some advantages to enteral feeding. Patients with acute pancreatitis caused by gallstones, who are strongly suspected of harboring common bile duct stones on the basis of organ failure or other signs of severe systemic toxicity (marked leukocytosis and/or fever), require evaluation for the presence of choledocholithiasis, preferably within the first 24 h of admission. ERCP with endosocopic biliary sphincterotomy and stone removal are indicated for patients with cholangitis, severe acute pancreatitis, or high clinical suspicion or definitive demonstration of persistent bile duct stones by other imaging techniques. Expectant management with interval cholecystectomy including intraoperative cholangiogram is appropriate for most patients with mild to moderate pancreatitis and an improving clinical course. Routine precholecystectomy ERCP is not recommended in patients with biliary pancreatitis. In ambiguous cases, where available, evaluation for bile duct stones can beperformed by endoscopic ultrasound or MRCP. The use of prophylactic antibiotics in necrotizing pancreatitis is not recommended in view of a recent prospective randomized double-blind trial that showed no benefit and in view of the concern that the prolonged use of potent antibiotic agents may lead to the emergence of resistant Gram-positive organisms and fungal infections in the necrotic pancreas. It is reasonable to administer appropriate antibiotics in necrotizing pancreatitis associated with fever, leukocytosis, and/or organ failure while appropriate cultures (including culture of CT-guided percutaneous aspiration of the pancreas) are obtained. Antibiotics should then be discontinued if no source of infection is found. CT-guided percutaneous aspiration with Gram's stain and culture is recommended when infected pancreatic necrosis is suspected. Treatment of choice of infected necrosis is surgical debridement. The timing of surgery is left to the discretion of the pancreatic surgeon. Patients who are medically unfit for open surgical debridement can be treated with less invasive surgical techniques, radiologic techniques, and, at times, endoscopic techniques in medical centers with these capabilities. Treatment of sterile pancreatic necrosis is generally medical during the first several weeks even in the presence of multisystem organ failure. Eventually, after the acute inflammatory process has subsided and coalesced into an encapsulated structure that is frequently called organized necrosis, debridement may be required for intractable abdominal pain, intractable nausea or vomiting caused by extrinsic compression of stomach or duodenum, or systemic toxicity (fever and/or intractable malaise). Debridement can be performed by surgical, endoscopic, or radiologic techniques.

Berdel D, Buhl R, Dierkesmann R, Niebling W, Schultz K, Ukena D, et al. National Disease Management Guideline for Asthma: Recommendations and evidence for 'asthma prevention' issues. Zeitschrift fur Arztliche Fortbildung und Qualitatssicherung 100(6) 2006: 425-430.

The National Disease Management Program (NDM Program) represents the basic content of structured, cross-sectoral Healthcare. In particular, the NDM Program is directed towards coordinating different disciplines and areas of Healthcare. The recommendations are developed through interdisciplinary consensus of the scientific medical societies on the basis of the best available evidence. Within this scope the scientific medical societies concerned with the prevention, diagnosis, therapy and rehabilitation of asthma consented upon a National Disease Management Guideline for Asthma in 2005. Among other things, the following cornerstones of asthma prevention were agreed upon: Breastfeeding and non-smoking were suggested as primary prevention measures for (expectant) parents. With respect to secondary prevention, recommendations have been made for allergen avoidance, active/passive smoking and immunotherapy. Regarding tertiary prevention, position statements on vaccination and specific immunotherapy are developed. The present paper presents both the original texts of the recommendations and the evidence underlying them.


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Bettoli V, Borghi A, Virgili A. Acne vulgaris: Guidelines for treatment. Rivista Italiana di Medicina Dell'Adolescenza 4(2) 2006: 23-28.

Acne vulgaris is a common skin disease affecting about 70-90% of adolescents. It is a multifactorial disease of the pilosebaceous units of the face, neck, chest and back, characterised by ductal hyperkeratinization, androgen-mediated seborrhoea, Propionibacterium acnes colonization of the follicle and inflammation. The features and the severity of acne are variable, depending on number, size and predominant type of lesions (inflamed lesions, non-inflamed lesions, scars). Significant psychosocial disabilities can arise from the disease. Frequently adolescents may experience poor self image, anxiety, depression and social isolation. As a consequence, an effective management of the disorder can have a considerable impact in patients with acne. The purpose of this paper is to help physicians in selecting an appropriate treatment among the vast number of therapeutic options available according to acne clinical presentation.

Billiard M, Bassetti C, Dauvilliers Y, Dolenc-Groselj L, Lammers GJ, Mayer G, et al. EFNS guidelines on management of narcolepsy. European Journal of Neurology 13(10) 2006: 1035-48.

Management of narcolepsy with or without cataplexy relies on several classes of drugs, namely stimulants for excessive daytime sleepiness and irresistible episodes of sleep, antidepressants for cataplexy and hypnosedative drugs for disturbed nocturnal sleep. In addition, behavioral measures can be of notable value. Guidelines on the management of narcolepsy have already been published. However contemporary guidelines are necessary given the growing use of modafinil to treat excessive daytime sleepiness in Europe within the last 5-10 years, and the decreasing need for amphetamines and amphetamine-like stimulants; the extensive use of new antidepressants in the treatment of cataplexy, apart from consistent randomized placebo-controlled clinical trials; and the present re-emergence of gamma-hydroxybutyrate under the name sodium oxybate, as a treatment of all major symptoms of narcolepsy. A task force composed of the leading specialists of narcolepsy in Europe has been appointed. This task force conducted an extensive review of pharmacological and behavioral trials available in the literature. All trials were analyzed according to their class evidence. Recommendations concerning the treatment of each single symptom of narcolepsy as well as general recommendations were made. Modafinil is the first-line pharmacological treatment of excessive daytime sleepiness and irresistible episodes of sleep in association with behavioral measures. However, based on several large randomized controlled trials showing the activity of sodium oxybate, not only on cataplexy but also on excessive daytime sleepiness and irresistible episodes of sleep, there is a growing practice in the USA to use it for the later indications. Given the availability of modafinil and methylphenidate, and the forseen registration of sodium oxybate for narcolepsy (including excessive daytime sleepiness, cataplexy, disturbed nocturnal sleep) in Europe, the place of other compounds will become fairly limited. Since its recent registration cataplexy sodium oxybate has now become the first-line treatment of cataplexy. Second-line treatments are antidepressants, either tricyclics or newer antidepressants, the later being increasingly used these past years despite few or no randomized placebo-controlled clinical trials. As for disturbed nocturnal sleep the best option is still hypnotics until sodium oxybate is registered for narcolepsy. The treatments used for narcolepsy, either pharmacological or behavioral, are diverse. However the quality of the published clinical evidences supporting them varies widely and studies comparing the efficacy of different substances are lacking. Several treatments are used on an empirical basis, specially antidepressants for cataplexy, due to the fact that these medications are already used widely in depressed patients, leaving little motivation from the manufacturers to investigate efficacy in relatively rare indications. Others, in particular the more recently developed substances, such as modafinil or sodium oxybate, are evaluated in large randomized placebo-controlled trials. Our objective was to reinforce the use of those drugs evaluated in randomized placebo-controlled trials and to reach a consensus, as much as possible, on the use of other available medications.

Bornhoft G, Wolf U, Von Ammon K, Righetti M, Maxion-Bergemann S, Baumgartner S, et al. Effectiveness, safety and cost-effectiveness of homeopathy in general practice - Summarized health technology assessment. Forschende Komplementarmedizin 13(SUPPL. 2) 2006: 19-29.

Introduction: The Health Technology Assessment report on effectiveness, cost-effectiveness and appropriateness of homeopathy was compiled on behalf of the Swiss Federal Office for Public Health (BAG) within the framework of the 'Program of Evaluation of Complementary Medicine (PEK)'. Materials and Methods: Databases accessible by Internet were systematically searched, complemented by manual search and contacts with experts, and evaluated according to internal and external validity criteria. Results: Many high-quality investigations of pre-clinical basic research proved homeopathic high-potencies inducing regulative and specific changes in cells or living organisms. 20 of 22 systematic reviews detected at least a trend in favor of homeopathy. In our estimation 5 studies yielded results


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indicating clear evidence for homeopathic therapy. The evaluation of 29 studies in the domain 'Upper Respiratory Tract Infections/Allergic Reactions' showed a positive overall result in favor of homeopathy. 6 out of 7 controlled studies were at least equivalent to conventional medical interventions. 8 out of 16 placebo-controlled studies were significant in favor of homeopathy. Swiss regulations grant a high degree of safety due to product and training requirements for homeopathic physicians. Applied properly, classical homeopathy has few side-effects and the use of high-potencies is free of toxic effects. A general health-economic statement about homeopathy cannot be made from the available data. Conclusion: Taking internal and external validity criteria into account, effectiveness of homeopathy can be supported by clinical evidence and professional and adequate application be regarded as safe. Reliable statements of cost-effectiveness are not available at the moment. External and model validity will have to be taken more strongly into consideration in future studies.

Dzieniszewski J, Jarosz M. Guidelines in the medical treatment of Helicobacter pylori infection. Journal of Physiology & Pharmacology 57(SUPPL. 3) 2006: 143-154. URL:

Scientific evidence based on controlled clinical research confirm substantial benefits resulting from the eradication of H. pylori infection in such pathologies of the alimentary tract as: gastric peptic and duodenal ulcer (active or confirmed in the future and ulcer disease complications), MALT (Mucosa Associated Limphoid Tissue) lymphoma, atrophic gastritis, past stomach resection, gastric cancer in the family. The above group of indications is strongly recommended for eradicative treatment. During the last several years there have been many guidelines made by international and national specialist groups. 'Test and treat' strategy of undiagnosed dyspepsia treatment is based on possibility to carry out non-invasive tests confirming H. pylori infection. First symptoms of dyspepsia in people over 45 years of age constitute recommendation for endoscopy, as well as symptoms assumed to be 'alarming' (loss of weight, anaemia, bloody vomiting, tarry stool, dysphagia) regardless of patient age. An individual approach to eradication is proposed in gastroesophageal reflux disease, and use of non-steroid anti-inflammatory drugs. Antibacterial activity towards H. pylori is shown by many antibiotics (amoxicillin, macrolides, tetracyclines) and some other chemotherapeutic agents (nitroimidazoles) and bismuth. PPIs are recommended, because through increase of pH in stomach they create conditions to act for antibiotics. During the stage of first line triple therapy, it is advised to apply PPI and two antibacterial medicines at the same time (PPI + amoxicillin+metronidazole or clarithromycin). Such therapeutic action ensures achievement of eradication of H. pylori infection in 80-90% of cases. In case of lack of treatment efficiency in the first-line therapy, 7-14 day treatment may be repeated using triple therapies (PPI + 2 antibiotics) substituting the antibiotic with the metronidazole or tetracycline, or quadruple therapies (PPI + bismuth citrate + 2 antibiotics). Side effects during eradicative treatments occur quite rarely (from 15 to 30%).

European Group on Graves Orbitopathy, Wiersinga WM, Perros P, Kahaly GJ, Mourits MP, Baldeschi L, et al. Clinical assessment of patients with Graves' orbitopathy: the European Group on Graves' Orbitopathy recommendations to generalists, specialists and clinical researchers. European Journal of Endocrinology 155(3) 2006: 387-9.

Freeman AF, Shulman ST. Kawasaki disease: Summary of the American Heart Association guidelines. American Family Physician 74(7) 2006: 1141-1150.

Kawasaki disease is an acute vasculitis of childhood that predominantly affects the coronary arteries. The etiology of Kawasaki disease remains unknown, although an infectious agent is strongly suspected based on clinical and epidemiologic features. A genetic predisposition is also likely, based on varying incidences among ethnic groups, with higher rates in Asians. Symptoms include fever, conjunctival injection, erythema of the lips and oral mucosa, rash, and cervical lymphadenopathy. Some children with Kawasaki disease develop coronary artery aneurysms or ectasia, ischemic heart disease, and sudden death. Kawasaki disease is the leading cause of acquired heart disease among children in developed countries. This article provides a summary of the diagnostic and treatment guidelines published by the American Heart Association.

Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision). Journal of Foot and Ankle Surgery 45(5 Supp) 2006: S2-S66.

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese


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people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.

Hensler S, Hoidn S, Jork K. DEGAM practice guideline for stroke. ZFA. Zeitschrift fur Allgemeinmedizin 82(9) 2006: 404-408.

Due to their high prevalence and high rate of mortality and subsequent disablement strokes and the treatment thereof play an important role in general practice. The aim was to set up a guideline for high quality treatment of stroke patients under the conditions of general practice. It follows the DEGAM 10-step-procedure with special emphasis on evidence-based Medicine and practicability. During the first (initial) phase the general practitioner's decisions are about immediate hospitalization or - if necessary - emergency treatment. After inpatient treatment the task is to provide for home-based rehabilitation and secondary prevention as follow-up. The major recommendations of the guideline are outlined hereafter. copyright Georg Thieme Verlag KG Stuttgart.

Houston D, Lee D, Mant M. Hyperhomocysteinemia. Thrombosis Interest Group of Canada, 2006. URL: http://www.tigc.org/eguidelines/hyperhomocysteinemia.htm [last accessed: 06.12.2006].

Hsieh ST. EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy. European Journal of Neurology 13(12) 2006.

Kerr R, Johnson A, Rochester AP. Development of clinical guidelines for the use of electrical stimulation in the management of urge urinary incontinence in women. Journal - Association of Chartered Physiotherapists in Women's Health 99 2006: 49-57.

This paper describes the process of developing clinical guidelines for the physiotherapy management of urge urinary incontinence using electrical stimulation. The work was undertaken as part of a Masters-level module at the University of Bradford, Bradford, UK. The authors highlight the pitfalls encountered and identify areas for further research. It has been ascertained from the literature that there is consistent support for the effectiveness of electrical stimulation, with success and cure rates ranging between 37% and 88%. A wide range of treatment parameters have been identified; however, there is a lack of consensus for the selection of stimulation parameters and further good-quality research is required.

Kopp I, Lelgemann M, Ollenschlager G. The German disease management guideline asthma: Methods and development process. Zeitschrift fur Arztliche Fortbildung und Qualitatssicherung 100(6) 2006: 411-418.

The German National Program for Disease Management Guidelines, which is being operated under the auspices of the German Medical Association (GMA), the Association of the Scientific Medical Societies (AWMF) and the National Association of Statutory Health Insurance Physicians (NASHIP), provides a conceptual basis for the disease management of prioritized healthcare aspects. The main objective of the program is to establish consensus of the medical professions on key recommendations covering all sectors of healthcare provision and facilitating the coordination of care for the individual patient through time and across interfaces. Within the scope of this program, the Scientific Medical Societies concerned with the prevention, diagnosis, treatment and rehabilitation of asthma in children, adolescents and adults have reached consensus on the core contents for a National Disease Management Guideline for Asthma. This consensus was reached by applying formal techniques and on the basis of the adaptation of recommendations from existing guidelines with high quality standards in methodology and reporting, and information from evidence reports.


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http://www.tigc.org/eguidelines/hyperhomocysteinemia.htm

Lund JN, Nystrom PO, Coremans G, Herold A, Karaitianos I, Spyrou M, et al. An evidence-based treatment algorithm for anal fissure. Techniques in Coloproctology 10(3) 2006: 177-180.

Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.

Mant M, Houston D, Vickars L. Hypercoagulable/Thrombophilic States. Thrombosis Interest Group of Canada, 2006. URL: http://www.tigc.org/eguidelines/hypercoagstates.htm [last accessed: 06.12.2006].

Maury EE, Flores RH. Acute Monarthritis: Diagnosis and Management. Primary Care 33(3) 2006: 779-793.

The diagnosis for an acute monarthritis may still be elusive, even after an extensive initial evaluation. For example, what should be done for a patient who has a paucity of extra-articular findings on physical examination and an inflammatory synovial fluid with negative Gram's stain, cultures, and crystals? Conservative management is always prudent. Assume the joint is infected and treat as such until proven otherwise, because infection carries the highest morbidity and mortality of all the common acute monarthopathies.

Maxion-Bergemann S, Bornhoft G, Sonderegger E, Renfer A, Matthiessen PF, Wolf U. Traditional Chinese Medicine (phytotherapy): Health Technology Assessment report - Selected aspects. Forschende Komplementarmedizin 13(SUPPL. 2) 2006: 30-41.

Objective: A summary of main aspects from a Health Technology Assessment report on Traditional Chinese Medicine (TCM) in Switzerland concerning effectiveness and safety is given. Materials and Methods: Literature search was performed through 13 databases, by scanning reference lists of articles and by contacting experts. Assessed were quality of documentation, internal and external validity. Results: Effectiveness: 43 articles concerning 'gastrointestinal tract and liver' were assessed. The studies covering 7,436 patients were undertaken in China (35), Japan (3), USA (2) and Australia (3); 33/43 being controlled studies. 34/40 show significantly better results in the TCM-treated group. A comparison of studies on results of treatment based on a diagnosis according to TCM criteria and studies on results of treatment according to Western diagnosis shows that treatment based on TCM diagnosis improves the result. The comparison of treatment by individual medication and standard medication showed a trend in favor of individual medication. Safety: TCM training and practice for physicians in Switzerland are officially regulated. Side effects occur, but no severe effects have been registered up to now in Switzerland. TCM medicinals are imported; admission regulations are being installed. Problems due to production abroad, Internet trade, self-medication or admixtures are possible. Conclusion: The evaluation of the literature search provides evidence for a basic clinical effectiveness of TCM therapy. Severe side effects were not observed in Switzerland. Regulations for trading and use of medicinals prevent treatment risks. Further clinical studies in a Western context are required.

May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. European Journal of Neurology 13(10) 2006: 1066-77.

Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this study was to give evidence-based recommendations for the treatment of these headache disorders based on a literature search and consensus amongst a panel of experts. All available medical reference systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT syndrome. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies resulting in level A, B or C recommendations and good practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly


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http://www.tigc.org/eguidelines/hypercoagstates.htm

effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as alternative treatments. Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute therapy when patients are extremely distressed and disabled by frequent attacks.

McCarley P. The KDOQI clinical practice guidelines and clinical practice recommendations for treating anemia in patients with chronic kidney disease: implications for nurses . Nephrology Nursing Journal. 33(4) 2006: 423-6, 445, 427-8.

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative recently published revised clinical practice guidelines and recommendations for the treatment of anemia. This article provides an overview of the new guidelines and recommendations, with a focus on the hemoglobin treatment range, iron status, use of erythropoiesis-stimulating agents, and adjuvant therapies.

Michigan Quality Improvement Consortium. Management and prevention of osteoporosis. Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.mqic.org/pdf/osteopor06.pdf [last accessed: 06.12.2006].

Michigan Quality Improvement Consortium. Adult preventive services (ages 50 - 65+). Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2050-65+).pdf [last accessed: 06.12.2006].

Michigan Quality Improvement Consortium. Adult preventive services (ages 18 - 49). Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2018-49).pdf [last accessed: 06.12.2006].

National Advisory Committee on Immunization (NACI). Varizig™ as the varicella zoster immune globulin for the prevention of varicella In at-risk patients. Canada Communicable Disease Report = Releve des Maladies Transmissibles au Canada 32(ACS-8) 2006. URL: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/acs-08/index.html [last accessed: 06.12.2006].

Reinhart K, Brunkhorst F, Bone H, Gerlach H, Grundling M, Kreymann G, et al. [Diagnosis and therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]. Anaesthesist 1 2006: 43-56.

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Senese V, Hendricks MB, Morrison M, Harris J. SUNA clinical practice guidelines: male urethral catheterization. Urologic Nursing. 26(4) 2006: 315.


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http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/acs-08/index.html

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/acs-08/index.html

http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2018-49).pdf

http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2018-49).pdf

http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2050-65+).pdf

http://www.mqic.org/pdf/MQIC%202006%20Adult%20Preventive%20Services%20(Ages%2050-65+).pdf

http://www.mqic.org/pdf/osteopor06.pdf

Senese V, Hendricks MB, Morrison M, Harris J. SUNA clinical practice guidelines: female urethral catheterization. Urologic Nursing. 26(4) 2006: 314.

Skalidis EI, Vardas PE. Guidelines on the management of stable angina pectoris. European Heart Journal 27(21) 2006.

Skerk V, Tambic-Andrasevic A, Andrasevic S, Kalenic S, Francetic I, Derezic D, et al. Guidelines for antimicrobial treatment and prophylaxis of urinary tract infections - Year 2006 . Infektoloski Glasnik 26(2) 2006: 47-52.

Recommendations for antimicrobial treatment and prophylaxis of urinary tract infections (UTI) have been made according to study results on the resistance of the most frequent causative agents of UTI to antimicrobial drugs. The Committee for monitoring bacterial resistance to antibiotics in the Republic of Croatia has been conducting this study since 1997. Uncomplicated cystitis is treated for 1, 3 or 7 days, complicated cystitis for 7 days, pyelonephritis 10-14 days, and complicated UTI7 to 14 days, rarely longer. For the treatment of cystitis the following drugs are used: fluoroquinolones, nitrofurantoin, betalactam antibiotics, and in cases of lower resistance trimethoprim- sulfamethoxazole. A single therapy with fluoroquinolones is administered to otherwise healthy young women with normal urinary tract in whom cystitis symptoms have been present for less than 7 days. Empirical antimicrobial therapy of pyelonephritis, recurrent and all complicated UTIs must be reviewed after urine culture finding is obtained. In the treatment of bacterial prostatitis and febrile UTIs in males, the drug of first choice is ciprofloxacin. Asymptomatic bacteriuria is treated in pregnant women, newborns, preschool children with urinary tract abnormalities, before invasive urological and gynecological procedures, in kidney transplant recipients, and in the first days of short-term urinary bladder catheterization. Antimicrobial prophylaxis is administered primarily one hour prior to diagnostic or therapeutic invasive urological procedures, using selected antimicrobial agents.

Tan D, Darmasetiawan S, Haines CJ, Huang KE, Jaisamram U, Limpaphayom KK, et al. Guidelines for hormone replacement therapy of Asian women during the menopausal transition and thereafter. Climacteric 9(2) 2006: 146-51.

These Guidelines summarize the position of an Expert Panel on Menopause in Asian Women regarding the use of hormone replacement therapy (HRT) during the menopausal transition and thereafter. They are intended to aid gynecologists, family physicians and other health-care professionals in providing optimal care to menopausal Asian women who desire HRT.

Tupker RA, Dubois AEJ, De Groot H, Knulst AC, Lucker GPH. Guidelines for immunotherapy of insect sensitivity. Nederlands Tijdschrift voor Dermatologie & Venereologie 16(7) 2006: 293-297.

Vignatelli L, Billiard M, Clarenbach P, Garcia-Borreguero D, Kaynak D, Liesiene V, et al. EFNS guidelines on management of restless legs syndrome and periodic limb movement disorder in sleep. European Journal of Neurology 13(10) 2006: 1049-65.

In 2003, the EFNS Task Force was set up for putting forth guidelines for the management of the Restless Legs Syndrome (RLS) and the Periodic Limb Movement Disorder (PLMD). After determining the objectives for management and the search strategy for primary and secondary RLS and for PLMD, a review of the scientific literature up to 2004 was performed for the drug classes and interventions employed in treatment (drugs acting on the adrenoreceptor, antiepileptic drugs, benzodiazepines/hypnotics, dopaminergic agents, opioids, other treatments). Previous guidelines were consulted. All trials were analysed according to class of evidence, and recommendations formed according to the 2004 EFNS criteria for rating. Dopaminergic agents came out as having the best evidence for efficacy in primary RLS. Reported adverse events were usually mild and reversible; augmentation was a feature with dopaminergic agents. No controlled trials were available for RLS in children and for RLS during pregnancy. The following level A recommendations can be offered: for primary RLS, cabergoline, gabapentin, pergolide, ropinirole, levodopa and rotigotine by transdermal delivery (the latter two for short-term use) are effective in relieving the symptoms. Transdermal oestradiol is ineffective for PLMD.

Wierman ME, Basson R, Davis SR, Khosla S, Miller KK, Rosner W, et al. Androgen therapy in women: an Endocrine Society Clinical Practice guideline. Journal of Clinical Endocrinology &


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Metabolism 91(10) 2006: 3697-710.

OBJECTIVE: The objective was to provide guidelines for the therapeutic use of androgens in women. PARTICIPANTS: The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, a methodologist, and a medical writer. The Task Force received no corporate funding or remuneration. EVIDENCE: The Task Force used systematic reviews of available evidence to inform its key recommendations. The Task Force used consistent language and graphical descriptions of both the strength of recommendation and the quality of evidence, using the recommendations of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group. The strength of a recommendation is indicated by the number 1 (strong recommendation, associated with the phrase "we recommend") or 2 (weak recommendation, associated with the phrase "we suggest"). The quality of the evidence is indicated by cross-filled circles, such that [1 cross-filled circle, 3 empty circles] denotes very-low-quality evidence, [2 cross-filled circles, 2 empty circles] low quality, [3 cross-filled circles, 1 empty circle] moderate quality, and [4 cross-filled circles] high quality. Each recommendation is followed by a description of the evidence. CONSENSUS PROCESS: Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications. The drafts prepared by the task force with the help of a medical writer were reviewed successively by The Endocrine Society's CGS, Clinical Affairs Committee (CAC), and Executive Committee. The version approved by the CGS and CAC was placed on The Endocrine Society's web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes. CONCLUSIONS: We recommend against making a diagnosis of androgen deficiency in women at present because of the lack of a well-defined clinical syndrome and normative data on total or free testosterone levels across the lifespan that can be used to define the disorder. Although there is evidence for short-term efficacy of testosterone in selected populations, such as surgically menopausal women, we recommend against the generalized use of testosterone by women because the indications are inadequate and evidence of safety in long-term studies is lacking. A review of the data currently available is presented, and areas of future research are outlined. To formulate clinical guidelines for use of testosterone in women, additional information will be necessary. This includes defining conditions that, when not treated with androgens, have adverse health consequences to women; defining clinical and laboratory parameters that distinguish those with these conditions; and assessing the efficacy and long-term safety of androgen administration on outcomes that are important to women diagnosed with these conditions. This necessary clinical research cannot occur until the biological, physiological, and psychological underpinnings of the role of androgens in women and candidate disorders are further elucidated.

Yehia H, Gerritsen A. Guidelines for the use of antithrombotics in elderly patients with atrial fibrillation. Tijdschrift voor Verpleeghuisgeneeskunde 31(4) 2006: 114-118.

Atrial fibrillation is the most prevalent cardiac arrhythmia. It is an important independent risk factor for thromboembolic stroke. Antithrombotic therapy with coumarin derivatives or antiplatelet drugs have been shown to be effective in reducing the relative risk of stroke from atrial fibrillation. In general, we have noticed a tendency among some physicians not to prescribe oral anticoagulants for the elderly, especially when there is a history of frequent falls. Based upon the results of large trials and statistical analyses, we recommend the use of oral anticoagulants for all patients with atrial fibrillation unless there is a contraindication for the use of such drugs. There are some contraindications, however age or predisposition to falls are not considered as a contraindication.

Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Annals of the Rheumatic Diseases 65(10) 2006: 1312-1324.

Objective: To develop evidence based recommendations for the management of gout. Methods: The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales. Results: 12 key propositions were generated after three Delphi rounds. Propositions included both non-pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The


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importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) are recommended. Conclusions: 12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.

Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society . Circulation 114(10) 2006: 5.


Cancer Care/Palliative Care

Ettinger DS, Bepler G, Bueno R, Chang A, Chang JY, Chirieac LR, et al. Non-small cell lung cancer clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network 4(6) 2006: 548-82.

Lardinois D, De Leyn P, Van Schil P, Porta RR, Waller D, Passlick B, et al. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. European Journal of Cardio Thoracic Surgery 30(5) 2006: 787-792.

The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.

Morgan Jr RJ, Alvarez RD, Armstrong DK, Chen LM, Copeland L, Fowler J, et al. Ovarian cancer: Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network 4(9) 2006: 912-939.


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Ovarian neoplasms consist of several histopathologic entities, and treatment depends on the specific tumor type. Epithelial ovarian cancer comprises most malignant ovarian neoplasms; however, other pathologic subtypes (such as less common ovarian histopathologies) must be considered. These guidelines discuss epithelial ovarian cancer as well as less common ovarian histopathologies, including germ cell neoplasms, mixed mullerian tumors of the ovary, and ovarian stromal tumors.

O'Brien SM, Keating MJ, Mocarski ES. Updated guidelines on the management of cytomegalovirus reactivation on patients with chronic lymphocytic leukemia treated with alemtuzumab. Clinical Lymphoma & Myeloma 7(2) 2006: 125-130.

The anti-CD52 monoclonal antibody alemtuzumab is highly active in the treatment of chronic lymphocytic leukemia (CLL) in patients with previously treated, relapsed, and/or refractory CLL as well as in patients with previously untreated disease. The general immunosuppressive impact and toxicities associated with alemtuzumab therapy are largely predictable and manageable. In particular, cytomegalovirus (CMV) reactivation is now a well-documented complication in patients receiving alemtuzumab. This article discusses several strategies for monitoring and treating CMV reactivation in patients with CLL receiving alemtuzumab-based therapy and provides practical recommendations for CMV management by building upon the guidelines published previously in 2004.


Mental Health and Learning Disabilities

Anonymous. Psychiatric evaluation of adults, second edition. American Journal of Psychiatry. 163(6) 2006: Supplement: 3-36.

Geyer D, Batra A, Beutel M, Funke W, Gorlich P, Gunthner A, et al. AWMF Guideline: Post-acute treatment of alcohol abuse and dependence. Sucht: Zeitschrift fur Wissenschaft und Praxis 52(1) 2006: 8-34.

Aim: To produce 52 guidelines (according to AWMF, 2001) for the post-acute treatment of patients with alcohol dependence. Methods: Systematic review of the literature, expert judgment and ultimate consensual agreement. Results: Measures for long-term treatment and aftercare are proposed to improve or re-establish the functioning and performance of chronically ill or disabled alcohol abusers in everyday life and in the work environment. Addiction-specific therapies and general treatment approaches (e. g. psychotherapy, occupational therapy) are recommended on the basis of evidence-based criteria (according to SIGN, 1999) and clinical judgments (according to APA, 1995) for an integrated and sequential approach to the treatment of inpatients and outpatients. Conclusions: These evidence-based guidelines can help physicians and practitioners in in-and out-patient settings to improve their psycho-, socio-, and pharmaco-therapeutic competences.

Meierkord H, Boon P, Engelsen B, Gocke K, Shorvon S, Tinuper P, et al. EFNS guideline on the management of status epilepticus. European Journal of Neurology 13(5) 2006: 445-450.

The objective of the current paper was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4 mg of lorazepam or 10 mg of diazepam directly followed by 15-18 mg/kg of phenytoin or equivalent fosphenytoin. If seizures continue for more than 10 min after first injection another 4 mg of lorazepam or 10 mg of diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of midazolam, propofol or barbiturates; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on the type and the cause. In most cases of absence


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SE, a small i.v. dose of lorazepam or diazepam will terminate the attack. Complex partial SE is initially treated such as GCSE, however, when refractory further non-anaesthetising substances should be given instead of anaesthetics. In subtle SE i.v. anaesthesia is required.

Michigan Quality Improvement Consortium. Management of adults with major depression. Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.mqic.org/pdf/depres_g06.pdf [last accessed: 06.12.2006].

Ossemann M, Bruls E, de Borchgrave V, De Cock C, Delcourt C, Delvaux V, et al. Guidelines for the management of epilepsy in the elderly. Acta Neurologica Belgica 106(3) 2006: 111-116.

Seizures starting in patients over 60 years old are frequent. Diagnosis is sometimes difficult and frequently under- or overrated. Cerebrovascular disorders are the main cause of a first seizure. Because of more frequent comorbidities, physiologic changes, and a higher sensitivity to drugs, treatment has some specificity in elderly people. The aim of this paper is to present the result of a consensus meeting held in October 2004 by a Belgian French-speaking group of epileptologists and to propose guidelines for the management and the treatment of epilepsy in elderly people.

Petitjean F. Therapeutic guidelines in schizophrenia. Encephale 32(5 III) 2006: S855-S857.

van Ruckevorsel K, Boon P, Hauman H, Legros B, Osseman M, Sadzot B, et al. Standards of care for non-convulsive status epilepticus: Belgian consensus recommendations. Acta Neurologica Belgica 106(3) 2006: 117-124.

Non-convulsive status epilepticus (NCSE) makes up around one-third of all cases of SE, affecting approximately 1,000 to 4,000 individuals per year in Belgium. Compared with convulsive SE, NCSE has received considerably less attention, is underdiagnosed and undertreated. However, if recognised, NCSE can however be treated successfully. A workshop was convened by neurologists from major Belgian centres to review the latest information on NCSE and to make recommendations on diagnosis and treatment. These recommendations are not only intended for neurologists, but also for primary care physicians and physicians in intensive care units. NCSE should be suspected whenever cases of fluctuating consciousness or abrupt cognitive or behavioural changes are noted. Confirmation of diagnosis by EEG should be obtained wherever possible. In view of the often subtle clinical signs, EEG is also vital for monitoring treatment outcome. Non-comatose patients should generally be treated in a neurology ward since referral to an ICU is unnecessary. First-line treatment should be an intravenous benzodiazepine. For many patients who fail to respond to benzodiazepines, intravenous valproate will successfully abrogate seizure activity. Intravenous phenytoin can be used in patients with focal NCSE in whom valproate is contraindicated or ineffective. Time and care should be spent in identifying an appropriate and effective antiepileptic drug regimen without recourse to anaesthesia. For comatose patients, treatment intensity should be graded according to epilepsy history, general medical state and prognosis. In some patients, intensive remedial measures may allow rapid resolution of NSCE, whereas in more vulnerable patients, such treatment may be counterproductive.

Wynaden D, Landsborough I, McGowan S. Best practice guidelines for the administration of intramuscular injections in the mental health setting. Int J Mental Health Nursing 15(3) 2006: 195-200.


Dentistry

American Dental Association Council on Scientific Affairs. Dental management of patients receiving oral bisphosphonate therapy: expert panel recommendations. Journal of the American Dental Association 137(8) 2006: 1144-50.

BACKGROUND: In light of the uncertainty surrounding the incidence of bisphosphonate-associated osteonecrosis of the jaw (BON) and concomitant risk factors, dentists have questioned how to manage


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http://www.mqic.org/pdf/depres_g06.pdf%20

the care of patients receiving oral bisphosphonate therapy. Expert panelists were selected by the American Dental Association Council on Scientific Affairs on the basis of their expertise in the relevant subject matter and on their respective dental or medical specialties, and the panel was tasked with developing guidance for dentists treating these patients. METHODS: There are no data from clinical trials evaluating dental management of the care of patients receiving oral bisphosphonate therapy and, therefore, these recommendations are based on a thorough review of the available literature relating to bisphosphonate use and osteonecrosis of the jaw. After reviewing the literature, the panel developed these recommendations based on their expert opinion. RESULTS: These panel recommendations focus on conservative surgical procedures, proper sterile technique, appropriate use of oral disinfectants and the principles of effective antibiotic therapy. CONCLUSIONS: The recommendations are a resource for dentists to use in their practice, in addition to the dentist's own professional judgment, the information available in the dental and medical literature, and information from the patient's treating physician. The recommendations must be balanced with the practitioner's professional judgment and the individual patient's preferences and needs.

American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. Journal of the American Dental Association 137(8) 2006: 1151-9.

BACKGROUND: With the dramatic increase in the amount of scientific information available about oral health, an evidence-based approach to oral health care and the practice of dentistry is necessary. There is a need to summarize, critique and disseminate scientific evidence and to translate the evidence into a practical format that is used easily by dentists The evidence-based clinical recommendations in this report were developed by an expert panel established by the American Dental Association Council on Scientific Affairs that evaluated the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride for caries prevention. The recommendations are intended to assist dentists in clinical decision making. TYPES OF STUDIES REVIEWED: MEDLINE and the Cochrane Library were searched for systematic reviews and clinical studies of professionally applied topical fluoride--including gel, foam and varnish--through October 2005. RESULTS: Panelists were selected on the basis of their expertise in the relevant subject matter. The recommendations are stratified by age groups and caries risk and indicate that periodic fluoride treatments should be considered for both children and adults who are at moderate or high risk of developing caries. Included in the clinical recommendations is a summary table that can be used as a chairside resource. CLINICAL IMPLICATIONS: The dentist, knowing the patient's health history and vulnerability to oral disease, is in the best position to make treatment decisions in the interest of each patient. These clinical recommendations must be balanced with the practitioner's professional expertise and the individual patient's preferences.


Sexual Health, BBV and related Topics

ACOG Committee on Gynecologic Practice. ACOG Committee Opinion: Number 345, October 2006: vulvodynia. Obstetrics & Gynecology 108(4) 2006: 1049-52.

Vulvodynia is a complex disorder that can be difficult to treat. It is described by most patients as burning, stinging, irritation, or rawness. Many treatment options have been used, including vulvar care measures, medication, biofeed training, physical therapy, dietary, modifications, sexual counseling, surgery. A cotton swab test is used to distinguish generalized disease from localized disease. No one treatment is effective for all patients. A number of measures can be taken to prevent irritation, and several medications can be used to treat the condition.

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstetrics & Gynecology 108(4) 2006: 1039-47.

Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that worldwide, 140,000 women die of postpartum hemorrhage each year-one every 4 minutes


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(1). In addition to death, serious morbidity may follow postpartum hemorrhage. Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan syndrome). Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. All obstetric units and practitioners must have the facilities, personnel, and equipment in place to manage this emergency properly. Clinical drills to enhance the management of maternal hemorrhage have been recommended by the Joint Commission on Accreditation of Healthcare Organizations (2). The purpose of this bulletin is to review the etiology, evaluation, and management of postpartum hemorrhage.

Anonymous. Guidelines for reducing the risk of viral transmission during fertility treatment . Fertility & Sterility 86(5 SUPPL) 2006: S11-S17. URL:

These guidelines provide strategies, based on scientific principles and clinical experience, for reducing the risk of virus transmission in couples seeking treatment for infertility.

Anonymous. Revised minimum standards for practices offering assisted reproductive technologies. Fertility & Sterility 86(5 SUPPL) 2006: S53-S56.

Anonymous. Repetitive oocyte donation. Fertility & Sterility 86(5 SUPPL) 2006: S216-S217.

Anonymous. Use of clomiphene citrate in women. Fertility & Sterility 86(5 SUPPL) 2006: S187-S193.

*CC is the best initial treatment for the majority of women whose infertility is associated with ovulatory dysfunction (anovulation, luteal phase deficiency). Combined with appropriately timed IUI, CC treatment also increases cycle fecundity in couples with unexplained infertility.*CC treatment generally should be limited to the minimum effective dose and to no more than six ovulatory cycles. Failure to conceive after successful CC-induced ovulation is indication for further evaluation to exclude other contributing causes of infertility.*Combination therapies involving CC and other agents (metformin, glucocorticoids, exogenous gonadotropins) may be effective when treatment with CC alone fails to induce ovulation. Alternative strategies for the CC-resistant woman include treatment with aromatase inhibitors or exogenous gonadotropins and, in selected patients, ovarian drilling.*CC treatment should be monitored (BBT, serum P concentration, urinary LH excretion) to ensure its effectiveness in ovulation induction.*Side effects of CC treatment are generally mild and well tolerated. The principal risk of CC treatment is an increased incidence of multifetal gestation (<10%).

Anonymous. Correct coding for laboratory procedures during assisted reproductive technology cycles. Fertility & Sterility 86(5 SUPPL) 2006: S168-S171.

New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with assisted reproductive technologies. It is important for professionals in the field of assisted reproductive technology (ART) to become familiar with them prior to their implementation. This document replaces the July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for Laboratory Procedures During Assisted Reproductive Technology.

Anonymous. Vaccination guidelines for female infertility patients. Fertility & Sterility 86(5 SUPPL) 2006: S28-S30.

Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age are often unaware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease on pregnancy outcome. The purpose of this ASRM Practice Committee document is to summarize current recommendations regarding vaccinations for women of reproductive age.

Anonymous. 2006 Guidelines for gamete and embryo donation. Fertility & Sterility 86(5 SUPPL) 2006: S38-S50.

The 2006 Guidelines for Gamete and Embryo Donation provide the latest recommendations for evaluation of potential sperm, oocyte, and embryo donors, incorporating recent information about optimal


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screening and testing for sexually transmitted infections, genetic diseases, and psychological assessments. This revised American Society for Reproductive Medicine Practice Committee document incorporates recent information from the US Centers for Disease Control and Prevention, the US Food and Drug Administration, and the American Association of Tissue Banks, with which all programs offering gamete and embryo donation services must be thoroughly familiar.

Perinatal HIV Guidelines Working Group. Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. Rockville (MD): U.S. Public Health Service, 2006. URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9868 [last accessed: 06.12.2006].

Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the use of antiretroviral agents in pediatric HIV infection. Bethesda: U.S. Department of Health and Human Services, 2006. URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9928 [last accessed: 06.12.2006].

Yee HS, Currie SL, Darling JM, Wright TL. Management and treatment of hepatitis C viral infection: Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Office. American Journal of Gastroenterology 101(10) 2006: 2360-2378.

Chronic hepatitis C virus (HCV) infection affects approximately 1.3% of the general U.S. population and 5-10% of veterans who use Department of Veterans Affairs medical services. Chronic HCV is clearly linked to the development of cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease requiring liver transplantation. The consequences of HCV infection constitute a significant disease burden and demonstrate the need for effective medical care. Treatment of chronic HCV is aimed at slowing disease progression, preventing complications of cirrhosis, reducing the risk of HCC, and treating extrahepatic complications of the virus. As part of a comprehensive approach to HCV management, antiviral therapy with peginterferon alfa combined with ribavirin is the current standard of care. Antiviral therapy should be provided to those individuals who meet criteria for treatment and who are at greatest risk for progressive liver disease. Many of these patients may have comorbid medical and psychiatric conditions, which may worsen while on antiviral therapy. Current antiviral regimens are associated with significant adverse effects that can lead to noncompliance, dose reduction, and treatment discontinuation. To overcome these barriers and to address these issues, it has become crucial to facilitate a multidisciplinary team who can respond to and provide HCV-specific care and treatment. Screening for HCV, preventing transmission, delaying disease progression, ensuring appropriate antiviral therapy, and managing treatment-related adverse effects can improve patient quality of life, treatment adherence, and ultimately, improve patient outcomes.


Child Health

Anonymous. The use of antiviral drugs for influenza: Recommended guidelines for practitioners. Paediatrics & Child Health 11(8) 2006: 520-526.

Each year, there is a significant burden of illness due to influenza A viruses, and occasionally strains of influenza B. While acknowledging the importance of immunization against influenza, it was thought appropriate to develop contemporary guidelines on the use of antiviral drugs for chemoprophylaxis and therapy of influenza illness, which are appropriate for the management of influenza in interpandemic periods. The present article is an abbreviated version of a full statement outlining recommendations that are the result of a joint effort supported by the Canadian Paediatric Society (CPS) and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. The guidelines reflect the current state of knowledge regarding the use of influenza antiviral drugs, and will be modified as additional research data become available. Additional information on strategies to prevent influenza illness in the interpandemic period may be obtained from the annual statement by the National Advisory Committee on Immunization.


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http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9928



Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 43(3) 2006: e1-13. URL: http://www.naspghan.org/PDF/PositionPapers/constipation.guideline.2006.pdf [last accessed: 06.12.2006].

Halperin SA. Recommendation for an adolescent dose of tetanus and diphtheria toxoids and acellular pertussis vaccine: Reassurance for the future. Journal of Pediatrics 149(5) 2006: 589-591.

Michigan Quality Improvement Consortium. Prevention and identification of childhood overweight. Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9788 [last accessed: 06.12.2006].

Michigan Quality Improvement Consortium. Management of persistent asthma in infants and children 5 years of age and younger. Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9790 [last accessed: 06.12.2006].

Michigan Quality Improvement Consortium. Management of persistent asthma in children older than 5 years of age. Southfield: Michigan Quality Improvement Consortium, 2006. URL: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9783 [last accessed: 06.12.2006].



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http://www.naspghan.org/PDF/PositionPapers/constipation.guideline.2006.pdf

C. Guidelines Implementation

Etxeberria Aguirre A, Rotaeche Del Campo R. Evidence-based clinical practice guidelines: Current development and future perspectives. Revista de Calidad Asistencial 21(5) 2006: 228-237.

Because of interest in clinical practice guidelines (CPG) as instruments for improving clinical practice, the production of these documents has markedly increased. In Spain, multiple documents described as CPG are promoted by various institutions (health systems, scientific societies, industry, etc.). However, recent evaluations of their quality reveal a wide margin for improvement in their design. CPG should be developed through a systematic and structured process. The essence of a CPG is the formulation of recommendations responding to a list of questions in which the management of a problem in a specific context can be summarized. The response to the list of questions through evaluating and summarizing the evidence constitutes the nucleus of the CPG and is what distinguishes it from other document types that provide recommendations based mainly on 'expert' opinion. Recommendations should be graded according to the quality of the evidence on which they are based. The highest level of evidence is provided by systematic reviews and consequently consultation of these studies should be a priority. There are several initiatives in Spain such as Guiasalud or Redeguias of the Red Tematica de Investigacion MBE (Thematic Network for Research on EBM) that work on this type of CPG design. An essential strategy is the coordination of parties interested in producing CPG (scientific societies, health systems, etc.). Lastly, for CPG to improve the population's health, they must be disseminated and systematically implemented.

Legare F, O'Connor AM, Graham ID, Saucier D, Cote L, Blais J, et al. Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice. Patient Education & Counseling 63(3 SPEC. ISS) 2006: 380-390.

Objective: To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice. Methods: Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants. Results: Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators. Conclusion: These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice. Practice implications: Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Leslie LK, Stallone KA, Weckerly J, McDaniel AL, Monn A. Implementing ADHD Guidelines in Primary Care: Does One Size Fit All? Journal of Health Care for the Poor and Underserved 17(2) 2006: 302-327. URL:

To determine if the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder (ADHD) guidelines require tailoring for different settings, the researchers used a mixed-method research design to review an ADHD quality improvement effort in community clinics and private offices in San Diego County. Clinically, no differences were noted in rates of ADHD in the two settings. Children in community clinics (58.3%) were more likely to report public insurance (p < .001), diverse ethnic backgrounds (p = .003), low household incomes (p < .001), single parent households (p = .009), and to screen positive for Oppositional Defiant Disorder/Conduct Disorder (p = .027). They were also more likely to have experienced socio-environmental stressors (p < .001) including foster care, homelessness, parental drug use, and domestic violence. No differences were noted by treatment received at 12 months post-evaluation by office type. Open-ended interviews with clinicians confirmed these findings and revealed a need for tailoring of implementation strategies to more closely fit the needs of children and families cared for in public sector settings.


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Rosenfeld RM, Shiffman RN. Clinical Practice Guidelines: A Manual for Developing Evidence-Based Guidelines to Facilitate Performance Measurement and Quality Improvement. Otolaryngology Head & Neck Surgery 135(4 SUPPL) 2006: S1-S28.

Rosenqvist M. Monitoring compliance to guidelines. Scandinavian Cardiovascular Journal 40(5) 2006: 260-261.

Sonnad SS, Matuszewski K. Control mechanisms for guideline implementation. Quality Management in Health Care. 15(1) 2006: 15-26.

OBJECTIVES: One approach to reducing health care costs while ensuring high-quality patient care is the use of medical practice guidelines. This study focuses on mechanisms that facilitate the implementation of guidelines primarily intended to reduce cost without increasing patient risk, using a multiinstitutional case study of a single guideline. SUBJECTS AND METHODS: We conducted semistructured interviews with physicians and administrators involved with guideline implementation in 61 academic medical centers. The interviews included questions on both implementation methods and the final success of implementation at each center. RESULTS: We identified 5 factors likely to be of importance to the guideline implementation process: (1) the use of a written form to routinize the process; (2) the acquisition of informed consent; (3) the presence of an active department chair (or section chief) to serve as an opinion leader; (4) the use of individual-level monitoring; and (5) the granting of financial incentives. CONCLUSIONS: This study allowed the identification of four processes for guideline implementation. For hospitals contemplating implementation of guidelines aimed toward cost reduction or selective use of various agents for other purposes, a decision process to identify the control mechanism best suited to an individual institution is a crucial step toward success.

Tan WC, Ait-Khaled N. Dissemination and implementation of guidelines for the treatment of asthma. International Journal of Tuberculosis & Lung Disease 10(7) 2006: 710-6.

Asthma remains a serious global health problem that affects people of all ages. Many asthma management guidelines, both national and international, are available, but they are seldom implemented. The implementation of guidelines remains a challenge worldwide, as barriers exist at several levels. These barriers are generic, such as poverty, inadequate resources and poor infrastructure, or specific, such as organisational, health care provider and patient factors. The barriers are, however, potentially correctable, and the goal of guideline implementation is to translate evidence-based asthma management recommendations into real-life practice to improve patient health. This state of the art article reviews the challenges and current status of and strategies for asthma dissemination and implementation globally, and highlights the specific strategies for such improvement in developing countries. [References: 53]

Weller K, Vetter-Kauzcok C, Kahler K, Hauschild A, Eigentler T, Pfohler C, et al. Guideline implementation in Merkel cell carcinoma: An example of a rare disease. Deutsches Arzteblatt. Ausg. A. 103(42) 2006: 2791-2796. URL:

Introduction: Little is known about the implementation of guidelines in rare diseases which, because of low incidence, are often based on a low level of evidence. Merkel cell carcinoma is an agressive skin malignancy which provides an example. Methods: A questionnaire survey relating to treatment of Merkel call carcinoma between 1998 and 2004, the time since publication of the first version of the guidelines was sent to 47 hospitals. Data were solicited on epidemiology, tumour grade and stage, treatment and clinical course. Results: Replies were received for 150 patients. The analysis suggests that guideline adherence is patchy. There were particularly strong variations in practice relating to adjuvant radiotherapy. This is important because guideline conformity in this area is associated with fewer recurrences. Discussion: The example of Merkel Cell carcinoma illustrates that the mere publication of guidelines is insufficient to ensure that best evidence is put into practice.



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