Agency For Health Care Policy And Research Research Articles

Effect of slow stroke back massage nursing (SSBMN) cutaneus stimulus on pain intensity on sweet food crawings (Arai Pinang) suffering low back pain (LBP)

Low back pain is the most common complaint. About 90% of the causes of LBP are mechanical factors. The normal anatomic structure of the body when used excessively or previously experienced trauma can cause stress or strain on muscles, tendons and ligaments. Actually the pain is minimized by using a back massage. AHCPR (Agency for Health Care Policy and Research) guidelines for non-pharmacological acute pain management are suitable interventions. Non-pharmacological interventions that can be done to treat pain are cutaneous stimulation, distraction, relaxation, guided imagination and hypnosis. This study aims to determine the effect of slow stroke back massage cutaneous stimulus on pain intensity in Ladu snack craftsmen (aria pinang) who suffer from low back pain in Pariaman City. The research design used is a quasi experiment. The number of samples is 14 respondents with purposive sampling technique. The independent variable was slow stroke back massage cutaneous stimulus while the dependent variable was pain intensity. This study used the Wilcoxon signed runk test.

Treatment of trauma-related vertebral body fractures of the thoracic and lumbar spine with orthotic devices : Areview

Trauma-related fractures of the thoracic and lumbar spine occur after exposure to high kinetic energy. To assign patients to the correct kind of treatment the AO spine classification is used. The aim was to describe the role of orthotic devices in the treatment of thoracic and lumbar fractures in the nondegenerative spine. Areview of the literature was carried out according to the PRISMA protocol (Preferred Reporting Items for Systematic reviews and Meta-Analyses) in PubMed, ScienceDirect, Cochrane and Google.Scholar. Atotal of 118 potentially important publications were found and 16studies with aprospective study design could be included in this analysis. RoB2 (Cochrane Risk of Bias tool in the second Version) in the case of randomized studies and the ROBINS‑I (Risk Of Bias In Nonrandomised Studies of Interventions) for nonrandomized studies were used to assess publication quality. The level of evidence was determined according to AHCPR (Agency for Health Care Policy and Research). In the case of fractures (AO types A0-A3) without degenerative changes in the bone structure of the thoracic and lumbar spine without indications for operative procedure, conservative treatment with analgesia, physiotherapy and early mobilization is recommended and orthotic treatment is not superior. Surgical treatment, even in cases where conservative treatment was possible, led to improved functionality and pain sensation faster but there were no differences in the long-term results. Assessing the neurological functional deficit, the functional success of the treatment and the kyphosis angle were measured in different ways, reducing the extent of comparability. Although mainly a level of evidence Ib-IIa could be assigned, nearly all included studies had ahigh risk of bias. In individual cases treatment with an orthotic device could be ahelpful add-on in conservative treatment of fractures in the thoracic and lumbar spine. Atreatment with orthotic devices alone cannot be recommended in these cases.

Can Patient Expectations of Returning to Work Documented Before, During, or at the End of Treatment Predict Actual Return to Work Post-treatment? An Evidence-Based Structured Systematic Review.

There is significant evidence that patient expectations can impact their treatment outcomes. The hypothesis of this systematic review was then the following. There will be significant consistent evidence as specified by the Agency for Health Care Policy and Research (AHCPR) guidelines that chronic pain patient (CPP) expectations for returning to work documented before, during, or at the end of treatment will predict actual return to work post-treatment. Of 316 references, 12 studies fulfilled inclusion criteria. These studies analyzed expectations of returning to work documented before, during, or at the end of treatment and utilized these for predicting return to work post-treatment. Relevant aspects of these studies were abstracted into tabular form for numerical analysis. All studies were rated independently by two reviewers for quality. The percentage of the 12 studies supporting the hypothesis was determined. This was then utilized to determine an AHCPR guideline rating for consistency. No studies had a rejection quality score. All studies were type 4. The hypothesis was supported by 91.6% of the studies. According to the AHCPR guidelines, this translated into an A rating: consistent findings from multiple type 4 studies. CPP expectations of returning to work as documented before, during, or at the end of treatment may predict actual return to work post-treatment.

Should We Still Use Red Flags in the Diagnosis of Low Back Pain?

Commentary The landmark clinical practice guideline on acute low back problems in adults published by the Agency for Health Care Policy and Research (AHCPR) in 1994 drew attention to the identification of red flags1. These refer to a group of clinical symptoms and signs that may indicate the potential presence of a serious underlying spine pathology like fracture, malignancy, infection, and cauda equina syndrome or a rapidly progressive neurologic deficit. In the absence of these signs and symptoms, diagnostic testing is not clinically helpful in the first 4 weeks of symptoms. Since then, the identification of red flags has become part of our clinical routine. It has also been adopted in many clinical practice guidelines for low back pain all over the world2. However, the utility of red flags in detecting serious spine pathologies has often been questioned, because of the high false-positive rates, the lack of standardization in the wide variety of red flags, and an overall lack of evidence for the diagnostic accuracy of recommended red flags2,3. The current study by Premkumar et al., “Red Flags for Low Back Pain Are Not Always Really Red. A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain,” provides further insight into the diagnostic accuracy of red flags in low back pain. This is possibly the largest single-center study on the utility of red flags in low back pain, with nearly 10,000 patients completing a standardized questionnaire of red flag questions before seeing their surgeon. The authors found that “while a positive response to a red flag question may indicate the presence of disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis.” They recommended that clinicians use caution when interpreting red flags as screening tools. Red flags are still red. This statement is supported by the increased likelihood of diagnoses of fracture, malignancy, infection, and cauda equina syndrome when there were positive responses to the red flag questions in this study, except for night pain. Combining 2 red flag symptoms increased the likelihood ratios further. Night pain as represented by the red flag question “Pain awakens from sleep” was nonspecific, with high false-positive rates of >85% for malignancy and >96% for infection when no other red flag symptom was present. It was not found to be a useful question to determine any diagnosis. However, it should be noted that night pain was not listed as a red flag in the 1994 AHCPR guideline. The medical history red flags that were related to pain for cancer detection in the AHCPR guideline were “Bed rest no relief” and “Duration of pain >1 month.”1 The clinical practice guideline published jointly by the American College of Physicians (ACP) and the American Pain Society (APS) in 2007 also did not include night pain as a key feature in the diagnostic workup for malignancy and infection, although “awakening due to back pain during the second part of the night…” was listed in the diagnostic workup for ankylosing spondylitis4. Interestingly, this 2007 guideline made no reference to “red flags,” but instead listed key features in the history and physical examination that were almost identical to red flags in the diagnostic workup for possible causes of low back pain. Both the AHCPR and the joint ACP/APS guidelines recommend performing a focused medical history and physical examination during which red flags or key features of serious underlying spine pathology are identified. These red flags or key features form part of the clinical assessment, quite unlike the current study design in which the red flag questions were in a self-administered questionnaire completed before the visit. The findings and recommendations of the current study should be interpreted in the context of its study design. Misinterpretation of the questions and incorrect filling out of the questionnaire could give rise to inaccurate data. The authors acknowledged that it is possible that patients may respond differently to the questions when asked verbally by their physician, who would be available for clarification of the question. It is also unrealistic to expect high sensitivity and specificity of diagnoses from just 2 to 4 questions in a self-administered questionnaire. This study clearly shows the inherent danger of identifying red flags using screening questionnaires alone, as a negative response to some of the red flag questions did not help to rule out red flag diagnoses. Clinical evaluation by medical history and physical examination is still mandatory.

The Agency for Healthcare Research and Quality and the Development of a Learning Health Care System

The Agency for Healthcare Research and Quality and the Development of a Learning Health Care System

Clinical practice guideline for the diagnosis and treatment of pituitary apoplexy

Abstract Classic pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by acute hemorrhage and/or infarction of the pituitary gland. PA is considered a neuroendocrinological emergency. However, there is no consensus about the best options for PA diagnosis and management. Objective To develop a clinical practice guideline with a number of recommendations for diagnosis and treatment of patients with PA based on the medical evidence available, in order to help clinicians involved in their care. Methods The clinical guideline for diagnosis and treatment of pituitary apoplexy issued in 2006 by the Neuroendocrinology Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN) and the British Clinical Practice Guideline published in 2011 were taken as the basis. The text has been adapted to the format used in most international medical journals. For this, after updated medical literature, the quality of evidence and the strength of the recommendations were evaluated using the system proposed by the Agency for Health Care Policy and Research (AHCPR). Conclusions Diagnosis of pituitary apoplexy should be considered in all patients with acute severe headache with or without neuro-ophthalmic signs. Patients with PA must undergo a complete history and physical examination. All patients with suspected pituitary apoplexy should have urgent blood samples drawn to test electrolytes, renal function, liver function, coagulation screen, complete blood count, and basal levels of pituitary and peripheral hormones, and to rule out adrenocorticotropic hormone (ACTH) deficiency. Formal visual field assessment should be performed when the patient is clinically stable. Magnetic resonance imaging (MRI) is the imaging test of choice to confirm diagnosis. Indications for empirical urgent corticosteroid therapy in patients with PA include hemodynamic instability, impaired consciousness, reduced visual acuity, and severe visual field defects. In patients with these severe neuro-ophthalmic signs, surgery should be considered. Surgery should preferably be performed within seven days of the onset of symptoms. Patients with mild and stable signs may be managed conservatively with careful monitoring. Treatment and long-term follow-up of patients with PA should be conducted by a multidisciplinary team consisting, amongst others, of an experienced pituitary neurosurgeon, an ophthalmologist, and an endocrinologist.

Guía de práctica clínica para el diagnóstico y tratamiento de la apoplejía hipofisaria

Classic pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by acute hemorrhage and/or infarction of the pituitary gland. PA is considered a neuroendocrinological emergency. However, there is no consensus about the best options for PA diagnosis and management. ObjectiveTo develop a clinical practice guideline with a number of recommendations for diagnosis and treatment of patients with PA based on the medical evidence available, in order to help clinicians involved in their care. MethodsThe clinical guideline for diagnosis and treatment of pituitary apoplexy issued in 2006 by the Neuroendocrinology Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN) and the British Clinical Practice Guideline published in 2011 were taken as the basis. The text has been adapted to the format used in most international medical journals. For this, after updated medical literature, the quality of evidence and the strength of the recommendations were evaluated using the system proposed by the Agency for Health Care Policy and Research (AHCPR). ConclusionsDiagnosis of pituitary apoplexy should be considered in all patients with acute severe headache with or without neuro-ophthalmic signs. Patients with PA must undergo a complete history and physical examination. All patients with suspected pituitary apoplexy should have urgent blood samples drawn to test electrolytes, renal function, liver function, coagulation screen, complete blood count, and basal levels of pituitary and peripheral hormones, and to rule out adrenocorticotropic hormone (ACTH) deficiency. Formal visual field assessment should be performed when the patient is clinically stable. Magnetic resonance imaging (MRI) is the imaging test of choice to confirm diagnosis. Indications for empirical urgent corticosteroid therapy in patients with PA include hemodynamic instability, impaired consciousness, reduced visual acuity, and severe visual field defects. In patients with these severe neuro-ophthalmic signs, surgery should be considered. Surgery should preferably be performed within seven days of the onset of symptoms. Patients with mild and stable signs may be managed conservatively with careful monitoring. Treatment and long-term follow-up of patients with PA should be conducted by a multidisciplinary team consisting, amongst others, of an experienced pituitary neurosurgeon, an ophthalmologist, and an endocrinologist.

Is Smoking Associated with Alcohol-Drug Dependence in Patients with Pain and Chronic Pain Patients? An Evidence-Based Structured Review

The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs). Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines. In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other. There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure.

Letters

Response to White and Cutting critique In their letter, published in the March issue of JWC, White and Cutting raised concerns about clinical visualisation of wound biofilm in the absence of a definitive assay or validation of visual observations with microscopic confirmation. While I acknowledge that science plays a critical role in extending our knowledge of the role of biofilm in wound healing, clinicians cannot ignore patients' needs, or the patterns we observe as experts in our practice, while we await such scientific developments.

The Impact of Comparative Effectiveness Research on Interventional Pain Management: Evolution from Medicare Modernization Act to Patient Protection and Affordable Care Act and the Patient-Centered Outcomes Research Institute

The Patient-Centered Outcomes Research Institute (PCORI) was established by the Affordable Care Act of 2010 to promote comparative effectiveness research (CER) to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis. The development of PCORI is vested in the Medicare Modernization Act (MMA) and the American Recovery and Reinvestment Act (ARRA). The framework of CER and PCORI describes multiple elements which are vested in all 3 regulations including stakeholder involvement, public participation, and open transparent decision-making process. Overall, PCORI is much more elaborate with significant involvement of stakeholders, transparency, public participation, and open decision-making. However, there are multiple issues concerning the operation of such agencies in the United States including the predecessor of Agency for Healthcare Research and Quality (AHRQ), the Agency for Healthcare Policy and Research (AHCPR), AHRQ Effectiveness Health Care programs, and others. The CER in the United States may be described at cross-roads or at the beginnings of a scientific era of CER and evidence-based medicine (EBM). However the United States suffers as other countries, including the United Kingdom with its National Health Services (NHS) and National Institute for Health and Clinical Excellence (NICE), with major misunderstandings of methodology, an inordinate focus on methodological assessment, lack of understanding of the study design (placebo versus active control), lack of involvement of clinicians, and misinterpretation of the evidence which continues to be disseminated. Consequently, PCORI and CER have been described as government-driven solutions without following the principles of EBM with an extensive focus on costs rather than quality. It also has been stated that the central planning which has been described for PCORI and CER, a term devised to be acceptable, will be used by third party payors to override the physician’s best medical judgement and patient’s best interest. Further, stakeholders in PCORI are not scientists, are not balanced, and will set an agenda with an ultimate problem of comparative effectiveness and PCORI that it is not based on medical science, but rather on political science and not even under congressional authority, leading to unprecedented negative changes to health care. Thus, PCORI is operating in an ad hoc manner that is incompatible with the principles of evidence-based practice. This manuscript describes the framework of PCORI, and the role of CER and its impact on interventional pain management. Key words: Patient-Centered Outcomes Research Institute (PCORI), comparative effectiveness research (CER), National Institute for Health and Clinical Excellence (NICE), Patient Protection and Affordable Care Act (ACA), Medicare Modernization Act (MMA), American Recovery and Reinvestment Act (ARRA), interventional pain management, interventional techniques, evidencebased medicine, systematic reviews.

Correlation between the AHCPR (Agency For Health Care Policy and Research) risk stratification and angiographic morphology in non-ST-segment elevation acute coronary syndrome

Risk stratification in acute coronary syndromes is an important diagnostic tool guiding future therapy. We evaluated the correlation between the AHCPR (Agency for Health Care Policy and Research) risk classification and angiographic morphology in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). A total of 163 patients hospitalized with the diagnosis of NSTE-ACS were prospectively enrolled. All the patients underwent AHCPR risk analysis followed by coronary angiography. Based on the AHCPR system, the patients were classified as low (n=25, mean age 55±10 years), intermediate (n=55, mean age 58±10 years), and high (n=83, mean age 61±11 years) risk groups. The three groups were similar with regard to gender, age, and coronary heart disease risk factors (p>0.05). Comparison of the high-risk group with intermediate+low-risk group with regard to lesion morphology showed significantly higher rates of complex lesions (31.9% vs. 4.0%, p=0.001), total occlusion (23.2% vs. 0%, p=0.001), and intracoronary thrombosis (13% vs. 2%, p=0.02) in the high-risk group. In univariate analysis, high risk was significantly associated with the presence of complex lesion, total occlusion, intracoronary thrombosis, and TIMI flow <III. Of these, only the presence of complex lesion (p=0.005) and TIMI flow <III (p=0.02) were associated with high risk in multivariate analyses. Our findings show that the incidence of high-risk coronary morphology is increased in NSTE-ACS patients having a high-risk profile according to the AHCPR classification.

What Is the Evidence for Chronic Pain Being Etiologically Associated with the DSM-IV Category of Sleep Disorder Due to a General Medical Condition? A Structured Evidence-Based Review

This is a structured evidence-based review of all available studies on the relationship between chronic pain and sleep problems as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) category of sleep disorder due to a general medical condition. To determine whether chronic pain is etiologically associated with this sleep category. Computer and manual literature searches yielded 146 references that addressed this area of study. One hundred and five studies were excluded from detailed review based on exclusion criteria detailed by this category of sleep disorders. Forty-one studies were reviewed in detail and sorted according to six natural groupings: multivariate analysis, prospective studies, path analysis, correlation between pain and sleep problems, univariate analysis using comparison groups, and do nonsedating drugs with analgesic properties improve sleep? Study characteristics were abstracted into tabular form and each report was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines. Each study was independently evaluated by two raters according to 12 quality criteria and an independent quality score was calculated. Studies were not utilized in the calculations unless their quality score (utilizing both raters) was greater than 60%. For each of the above groupings, an average quality score was calculated and a calculation performed as to the percentage of studies that supported the hypothesis that pain is etiologically related to the above DSM-IV category of sleep disorders. Finally, the strength and consistency of the evidence for this hypothesis was rated according to the AHCPR guidelines. Of the 41 reports, all had quality scores greater than 60%. In all the above groupings except for multivariate analysis, 100% of the studies supported this hypothesis. In the multivariate analysis grouping, 77.2% of the studies supported this hypothesis. The strength and consistency of this evidence was rated at A (highest possible) for all study groupings except multivariate (B rating) and path analysis where there were too few studies to generate a conclusion. For all the studies combined, 89.7% of the studies supported this hypothesis. This evidence was rated as A: consistent, multiple studies. The results of this evidence-based structured review indicate that for the pain-sleep studies defined by the DSM-IV category of sleep disorder due to a general medical condition,chronic pain may be etiologically related to that sleep problem. However, these results do not preclude this relationship from being bidirectional.

Clinical Risk Stratification in the Emergency Department Predicts Long-Term Cardiovascular Outcomes in a Population-Based Cohort Presenting With Acute Chest Pain

The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all EDs in Olmsted County, Minnesota. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of noncardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and at a median follow-up of 7.3 years, and mortality through a median of 16.6 years.The 2271 patients were classified as follows: 436 (19.2%) as high risk, 1557 (68.6%) as intermediate risk, and 278 (12.2%) as low risk. Thirty-day MACCE occurred in 11.5% in the high-risk group, 6.2% in the intermediate-risk group, and 2.5% in the low-risk group (p < 0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate-risk (hazard ratio [HR], 1.91; 95% confidence intervals [CI], 1.33-2.75) and high-risk groups (HR, 2.45; 95% CI, 1.67-3.58). Intermediate- and high-risk patients demonstrated a 1.38-fold (95% CI, 0.95-2.01; p = 0.09) and a 1.68-fold (95% CI, 1.13-2.50; p = 0.011) higher mortality, respectively, compared to low-risk patients at 16.6 years. At 7.3 and at 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk.In conclusion, a widely applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from a more aggressive cardiovascular risk factor management strategy.

An Introduction to an Evidence-Based Approach to Interventional Techniques in the Management of Chronic Spinal Pain

Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. Clinical practice guidelines present statements of best practice based on a thorough evaluation of the evidence from published studies on the outcomes of treatment. In November 1989, Congress mandated the creation of the Agency for Healthcare Policy and Research (AHCPR). AHCPR was given broad responsibility for supporting research, data development, and related activities. Associated with this mandate, the National Academy of Sciences published a document indicating that guidelines are expected to enhance the quality, appropriateness, and effectiveness of health care services. Guidelines as a whole have been characterized by multiple conflicts in terminology and technique. These conflicts are notable for the confusion they create and for what they reflect about differences in values, experiences, and interest among different parties. Despite this confusion, public and private development of guidelines is growing exponentially. There are only limited means to coordinate these guidelines in order to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of individual guidelines. Significant diversity exists in clinical practice guidelines. The inconsistency amongst guidelines arises from variations in values, tolerance for risks, preferences, expertise, and conflicts of interest. In 2000, the American Society of Interventional Pain Physicians (ASIPP) first created treatment guidelines to help practitioners. There have been 4 subsequent updates. These guidelines address the issues of systematic evaluation and ongoing care of chronic or persistent pain, and provide information about the scientific basis of recommended procedures. These guidelines are expected to increase patient compliance, dispel misconceptions among providers and patients, manage patient expectations reasonably, and form the basis of a therapeutic partnership between the patient, the provider, and payors. The ASIPP guidelines are based on evidence-based medicine (EBM). EBM is in turn based on 4 basic contingencies: the recognition of the patient's problem and the construction of a structured clinical question; the ability to efficiently and effectively search the medical literature to retrieve the best available evidence to answer the clinical question; clinical appraisal of the evidence; and integration of the evidence with all aspects of the individual patient's decision-making to determine the best clinical care of the patient. Evidence synthesis for guidelines includes the review of all relevant systematic reviews and individual articles, grading them for relevance, methodologic quality, consistency, and recommendations.

Do Opioids Induce Hyperalgesia in Humans? An Evidence-Based Structured Review

DESIGN/OBJECTIVES: Consistent rodent evidence indicates that opioid exposure will decrease the rodent's pain threshold (ptr). This is termed opioids-induced hyperalgesia (OIH). Currently, the consistency of the evidence for the occurrence of OIH in humans is unclear. This is a structured evidence-based review for all levels of evidence (all studies and case reports) on OIH in humans in order to determine the consistency of this evidence. Computer and manual literature searches yielded 504 OIH references (human and animal). Of these, 48 remained after application of inclusion/exclusion criteria. These references addressed 10 hypotheses that the OIH literature has utilized to test for the possibility of OIH in humans. These are the following: opioid addicts maintained on opioids will have decreased ptr and/or tolerance; detoxifying opioid addicts from opioids will increase their ptr and/or tolerance; stopping, decreasing, or rotating to a different opioid or detoxifying from an opioid will improve pain and/or allodynia; chronic pain patients(CPPs) placed on opioids will develop decreased ptr and/or tolerance; CPPs on opioids will have decreased ptr and/or tolerance vs CPPs not on opioids; opioid infusion in normal volunteers or CPPs will decrease ptr and/or tolerance; former opioid addicts exposed to opioids will demonstrate a decrease in ptr and/or tolerance; opioid infusion in normal volunteers will increase secondary hyperalgesia as measured by allodynia or hyperalgesia; perioperative opioids will increase postoperative pain and/or opioid requirements; and placement on opioids postsurgery leads to progressive increased intake (acute tolerance). Each report was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 14 quality criteria with a quality score calculated. For studies under each hypothesis, an average quality score and the percentage of studies supporting the hypothesis was calculated. Finally, for studies under each hypothesis, utilizing AHCPR criteria, a consistency rating was derived based on the percentage score of studies supporting the hypothesis. Two studies had quality scores below 65% and were not utilized. Overall, the strongest evidence (consistent, A) came from opioid infusion studies in normal volunteers as measured by secondary hyperalgesia. This evidence was supported by inconsistent evidence (C) from: studies addressing opioid infusions in normal volunteers or CPPs for decreasing ptr and/or tolerance; and studies addressing increases in postop opioid requirements or pain if peri-opioids were utilized. For the other seven hypotheses, there were too few studies to draw a conclusion or the evidence for the hypothesis were case reports or the results of the studies within the hypothesis were not interpretable. There is not sufficient evidence to support or refute the existence of OIH in humans except in the case of normal volunteers receiving opioid infusions. Prospective CPP clinical studies measuring ptrs and tolerances pre- and post-opioid placement with CPP non-opioid control groups are required.

Pressure ulcer prevention in intensive care patients: guidelines and practice

Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention. The design of this study was a cross-sectional study (point prevalence). Setting The study setting was intensive care units. The sample consisted of 169 patients - 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards. The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients. The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.

Currently available treatment guidelines for men with lower urinary tract symptoms

As a result of pressure from the USA Federal Government, the Agency for Health Care Policy and Research (AHCPR) was formed in the late 1980s to develop guidelines for the evaluation and treatment of common conditions characterized by contributing individually and collectively to a significant portion of the healthcare expenditure in the USA. The urological condition chosen as a target was BPH, which at the time was mostly treated surgically and with nearly 300 000 TURPs being performed annually represented the second most common procedure under Medicare.The AUA had independently recognized several problems with the delivery of care for certain urological conditions, including BPH [1,2]. These problems were:• Significant geographical variability in resource utilization and surgical rates.• Lack of standardized evaluation and assessment.• Lack of standardized indications for treatment.• Lack of standardized outcome assessment and quality of care indicators.• Significant contributor to overall healthcare cost.• Significant contributor to revenue of practising urologists.In this environment, characterized by an increasing tension between providers and payers, the AUA initiated its own guideline effort and focused on several common diseases including BPH. However, the panel assigned to BPH was taken over by the AHCPR and over time developed the first systematic review of the literature and a comprehensive evaluation, and a treatment guideline for BPH was published in 1994 [3–5].Internationally a WHO-sponsored consensus conference effort started also in the early 1990s, and in 1991 the first of a long and successful series of conferences resulted in the publication of a book detailing a worldwide consensus regarding virtually all aspects of the aetiology, evaluation, and treatment of BPH [6].Since then the AUA has updated its guidelines in 2003 and is currently undertaking another update; the European Association of Urology (EAU) has published several iterations of its guidelines; the WHO consensus documents were updated several times, the last modification being the result of a 2005 consultation; and many countries and professional organizations have published their own guidelines, more or less following the patterns set by the larger multinational organizations [7].

Foreword

THIS YEAR marks the 15-year anniversary of the release of the landmark Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Clinical Practice Guideline. 1 Agency for Healthcare Policy and Research (AHCPR)Acute Pain Management: Operations or Medical Procedures and Trauma. Clinical Practice Guideline. AHCPR Publication 92-0032. US Public Health Service, Rockville, MD1992 Google Scholar The Guideline represented a milestone in pain management because it suggested a systematic, evidence-based method for addressing the phenomenon of acute pain. As the coordinator of an acute pain service in a large hospital in Louisiana at the time, I vividly recall the medical director of the acute pain service racing down the hall to me with a draft of the document in his hand. He excitedly said, “This guideline will forever change the way people treat acute pain!” Indeed, advances in science, technology, and clinical practice over the past 15 years have resulted in rapid changes and growth in the field of acute postoperative pain management. Though many patients continue to experience undertreated postoperative pain, there have been numerous improvements and nurses have been key to the progress made and in shaping the future of postoperative pain management.

Basics Are Best in Dealing With Pressure Ulcers

Basics Are Best in Dealing With Pressure Ulcers

Neue Konzepte der Leitlinienmethodik

The German Society for Digestive and Metabolic Diseases (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS) has already published an impressive number of clinical practice guidelines, with more topics currently being under development. The guideline method within the DGVS as well as between medical professional societies varies greatly. In particular, the levels of evidence as well as the grades of recommendations are often applied very differently. Most guidelines in Germany use the grades of the US Agency for Health Care Policy and Research (AHCPR), which were first published in 1992. Some newer guidelines, e.g., the ulcerative colitis guideline of the DGVS or the guidelines of the German Diabetes Association, try to circumvent problems of this method. They adopted variations of the very simple AHCPR grades. Sometimes these new grading methods have serious shortcomings too. They may not be reproducible, ignore important parts of the consensus process, can only be applied to therapeutic interventions, or they do not adequately distinguish between the strength of a recommendation and the quality of evidence. Meanwhile, an enormous number of different and partially contradictory methodologies for the grading of guideline recommendations are being used. In the GRADE working group several renowned clinical epidemiologists came together to develop a uniform grading systematic that avoids the problems of earlier guideline methods. With GRADE first the quality of evidence is assessed in a systematic manner. The quality of each study plays an important role in this process. Hence randomised trials of poor quality can end up with a lower overall quality rating than well performed observational trials. The strength of recommendation is based on the balance between the expected benefit and harm of the intervention in the respective population for which the recommendations of the guideline are made. The quality of evidence is only one factor contributing to the strength of recommendation. The GRADE method can be more cumbersome in its application compared to older methods. Nevertheless, more and more organisations are adopting GRADE for their guidelines and recommendations. Possibly the DGVS guidelines could benefit from this new system too.