Clinical Practice Guidelines For Treatment Research Articles

Evaluation of clarity of presentation and applicability of monitoring instructions for patients using lithium in clinical practice guidelines for treatment of bipolar disorder.

ObjectivesClinical practice guidelines (CPGs) for treatment of bipolar disorder (BD) aim to provide guidance to health care professionals on monitoring of patients using lithium. The aim was to assess the clarity of presentation and applicability of monitoring instructions for patients using lithium in CPGs for treatment of BD.Methods CPGs for treatment of BD were selected from acknowledged professional organizations from multiple continents. CPGs were rated on the clarity of presentation and applicability of lithium monitoring instructions using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The applicability of monitoring instructions was assessed according to the Systematic Information for Monitoring (SIM) score. Monitoring instructions were considered applicable when a SIM score of ≥3 was found.ResultsThe clarity of presentation for six out of the nine CPGs was good (>70%) using the AGREE II tool. Only one CPG scored >70% on applicability. Descriptions of the resource implications and facilitators of and barriers to monitoring were most often missing. All CPGs contained instructions for monitoring of lithium serum levels and renal and thyroid function. Information provided in monitoring instructions (n = 247) was in general applicable to clinical practice (77%) based on the SIM score. Overall, a median SIM score of 3 (interquartile range 3‐4) was found.ConclusionsImprovement of the applicability of CPGs is recommended, and can be achieved by describing the resource implications and facilitators of and barriers to monitoring. In addition, information on critical values and instructions on how to respond to aberrant monitoring parameters are needed. With such improvements, CPGs may better aid health care professionals to monitor patients using lithium.

Evidenced-Based Guidelines on the Treatment of Fibromyalgia Patients: Are They Consistent and If Not, Why Not? Have Effective Psychological Treatments Been Overlooked?

This article presents an overview and highlights the inconsistencies of 4 recent clinical practice guidelines for treatment of fibromyalgia patients related to study inclusion criteria, outcome measures used, ranking system used, and composition of the review panels. The discrepancies suggest a need to create a guideline consensus to synthesize guidelines.

A single center observational study on emergency department clinician non-adherence to clinical practice guidelines for treatment of uncomplicated urinary tract infections.

BackgroundThe Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG).MethodsA single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student’s t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment.Results103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive non-adherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4–2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3–11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1–63.0, P = 0.01).ConclusionsPatients with cystitis with back or abdominal pain only were most likely to receive non-adherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: Recommendations for treatment

Clinical practice guidelines. To develop the first Canadian clinical practice guidelines for treatment of neuropathic pain in people with spinal cord injury (SCI). The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. The CanPainSCI Working Group reviewed the evidence for different treatment options and achieved consensus. The Working Group then developed clinical considerations for each recommendation. Recommendations for research are also included. Twelve recommendations were developed for the management of neuropathic pain after SCI. The recommendations address both pharmacologic and nonpharmacologic treatment modalities. An expert Working Group developed recommendations for the treatment of neuropathic pain after SCI that should be used to inform practice.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders.

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014. The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified. In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice. Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management. Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Clinical practice guidelines for treatment of acne vulgaris: a critical appraisal using the AGREE II instrument

A significant number of clinical practice guidelines (CPGs) about the treatment of acne vulgaris in adolescents and adults have been published worldwide. However, little is known about the quality of CPGs in this field. The aim of this study was to appraise the methodological quality of published acne vulgaris CPGs. We performed a systematic review of published CPGs on acne vulgaris therapy from July 2002 to July 2012. Three reviewers independently assessed each CPG using the AGREE II instrument. A standardized score was calculated for each of the six domains. Our search strategy identified 103 citations but just six met our inclusion criteria. Agreement among reviewers was very good: 0.981. The domains that scored better were: "scope and purpose" and "clarity and presentation". Those that scored worse were "stakeholder involvement", "rigor of development", and "applicability". The European and the Malaysian CPGs were the only recommended with no further modifications. In addition, the Mexican, Colombian and the United States guidelines were recommended with provisos, with lower scores regarding stakeholder involvement, rigor of development and applicability. Only two guidelines clearly reported outcome measures for evaluating efficacy or included quality of life outcomes. CPGs varied regarding the consideration of light/laser therapy or consideration of complementary/alternative medicines. None of them included cost considerations of drugs such as systemic isotretinoin. In conclusion, published acne vulgaris CPGs for acne therapy vary in quality with a clear need to improve their methodological rigor. This could be achieved with the adherence to current CPGs development standards.

Utility of a Clinical Practice Guideline in Treatment of Chylothorax in the Postoperative Congenital Heart Patient

Chylothorax after congenital heart surgery is a common complication with associated morbidities, but consensus treatment guidelines are lacking. Variability exists in the duration of medical treatment and timing for surgical intervention. After institution of a clinical practice guideline for management of postoperative chylothorax at a single center, pediatric cardiothoracic intensive care unit (ICU) in June 2010, we retrospectively analyzed 2 cohorts of patients: those with chylothorax from January 2008 to May 2010 (early cohort; n=118) and from June 2010 to August 2011 (late cohort; n=45). Data collected included demographics, cardiac surgical procedure, treatments for chylothorax, bloodstream infections, hospital mortality, length of hospitalization, duration of mechanical ventilation, and device utilization. There were no demographic differences between the cohorts. No differences were found in octreotide use or surgical treatments for chylothorax. Significant differences were found in median times to chylothorax diagnosis (9 in early cohort versus 6 days in late cohort, p=0.004), ICU length of stay (18 vs 9 days, p=0.01), hospital length of stay (30 vs 23 days, p=0.005), and total durations of mechanical ventilation (11 vs 5 days, p=0.02), chest tube use (20 vs 14 days, p=0.01), central venous line use (27 vs 15 days, p=0.001), and NPO status (9.5 vs 6 days, p=0.04). Institution of a clinical practice guideline for treatment of chylothorax after congenital heart surgery was associated with earlier diagnosis, reduced hospital length of stay, mechanical ventilation, and device utilization for these patients.

Using quality indicators to monitor changes in adherence to clinical practice guidelines for treatment of ductal carcinoma in situ (DCIS) of the breast.

246 Background: Evaluation of the management of DCIS poses challenges, as standard breast cancer outcome measures such as mortality do not apply. Therefore, quality indicators (QIs) were previously developed through an interprovincial, multidisciplinary Delphi process to assess the quality of DCIS treatment and adherence to clinical practice guidelines. Population based treatment of DCIS was then compared over time using these QIs. Methods: Patients diagnosed with DCIS from 2000 to 2001 and 2009 to 2011 were identified on a population basis from the Alberta Cancer Registry and a province-wide prospectively collected synoptic medical report (WebSMR) in Alberta, Canada. Patient charts were reviewed retrospectively and QIs abstracted. Results: A total of 620 patients were identified in the study periods. Results are summarized in the table. In comparison to the earlier group, the recent cohort showed significant improvement in radiation oncology referral, radiation post lumpectomy, and complete pathology reporting. Axillary staging significantly increased from 20% (axillary dissection in 2000 to 2001) to 73% (sentinel node biopsy 2009 to 2011). Other QIs did not differ significantly. Conclusions: Adherence to clinical practice guidelines for DCIS in Alberta measured using developed QIs have shown significant improvements, particularly in pathology reporting, referral to radiation oncologists and uptake of radiation therapy for patients treated with breast conserving surgery. Rates of sentinel node biopsy seem unacceptably high, which requires further investigation. [Table: see text]

Should Empiric Therapy for Severe Community Acquired Pneumonia Always Include MRSA Coverage

PURPOSE: The Infectious Disease Society of America has recently published Clinical Practice Guidelines for treatment of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections. [CID 2011;52(1 February):1-38.] Included is a recommendation to empirically cover MRSA with vancomycin, linezolid or clindamycin for severe Community Acquired Pneumonia (CAP) as defined by: 1) requirement for ICU admission, 2) necrotizing or cavitary infiltrates or 3) empyema. Prevalence of MRSA in the community was evaluated before adopting the IDSA recommendation to empirically cover MRSA in all patients with severe CAP where the only risk factor is ICU admission.

Evaluation of nitric oxide as a novel diagnostic marker for hepatocellular carcinoma

IntroductionLiver cancer is the sixth most common cancer worldwide. HCC is the most common primary tumor of the liver. The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for treatment of hepatobiliary cancers propose surveillance for the early detection of HCC by liver ultrasonography every 3–6months and evaluation of AFP. AFP >200ng/ml is considered diagnostic for HCC, although fewer than half of patients of HCC may generate levels that are high, so that the specificity of AFP is close to 100% but the sensitivity is 45%. Nitrite/Nitrate is a stable end product of nitric oxide increase in patients with HCC. AimIt was to evaluate nitric oxide as a novel diagnostic marker for hepatocellular carcinoma. MethodsEighty patients and 15 normal individuals enrolled in the study: Group (1) 15 normal individuals. Group (2) 30 patients with chronic liver disease without HCC. Group (3) 50 patients with HCC. History taking, clinical examination, (detection of liver masses, ascites, spleen size, and grade of encepathalopathy), and Child-pugh scoring. Laboratory investigation: (AlT, AST, bilirubin, albumin, prothrombin, GGT, platelet count, AFP, nitric oxide, HBs-Ag, and HCV-Ab). Abdominal ultrasonography and spiral CT. ResultsThe median level of nitric oxide was significantly higher in Group (3) (170μmol/l) than in Group (2) (56μmol/l) than in Group (1) (22μmol/l), with a sensitivity of (68%) and specificity of (90%) at a cutoff level of 110μmol/l and area under the curve of (0.810).While AFP, at a cutoff level of 200ng/ml had a sensitivity of (52%), specificity of (100%) and area under the curve (0.855). Indeed nitric oxide was high in 42% of AFP-negative HCC patients. ConclusionNitric oxide is a novel diagnostic marker for hepatocellular carcinoma, the simultaneous determination of serum nitric oxide and AFP gave significant improvement in detection of HCC patients compared to that of AFP alone.

Critical Appraisal of Quality of Clinical Practice Guidelines for Treatment of Psoriasis Vulgaris, 2006–2009

Numerous international clinical guidelines for management of psoriasis have recently been published. We evaluated the quality of guidelines published between 2006 and December 2009 using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Eight guidelines from five separate working groups fulfilled inclusion criteria and were evaluated. Four used the standards established by the AGREE instrument in the process of development of their guidelines. Each of the guidelines uniformly received high domain scores (i.e., > 90%) for scope and purpose (range of 94-100%), and clarity and presentation (range of 92-100%). Nevertheless, each of the eight guidelines had important shortcomings (item scores < or = 2/4, in which 4 indicates strongly agree and 1 indicates strongly disagree that specific items have been adequately addressed) in at least one item including: stakeholder involvement (by lack of piloting and inadequate determination of patient views), development rigor (inadequate procedure for updating), applicability (by lack of discussion on organizational barriers), and editorial independence (from funding body). Despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.

Advanced colorectal cancer: ESMO Clinical Practice Guidelines for treatment

Advanced colorectal cancer: ESMO Clinical Practice Guidelines for treatment

Effect of adding milnacipran to pregabalin in the management of fibromyalgia: a randomized, open-label, controlled study

Clinical practice guidelines for treatment of fibromyalgia (FM) emphasize the role of pharmacologic interventions that address multiple symptoms, such as pain, fatigue, and sleep disturbance. Patients with FM may benefit from a combination of medications with complementary mechanisms of action that could yield additive or synergistic effects. A rational combination therapy approach would be milnacipran, a dual reuptake inhibitor thought to augment norepinephrine and serotonin neurotransmitter signaling in descending pain modulatory neurons, plus pregabalin, which may inhibit nociceptive signaling in ascending fibers through voltage-gated calcium channels.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials. A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors. Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated. All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Current practice patterns in the treatment of perforated appendicitis in children.

The treatment of perforated appendicitis in children often involves a combination of surgical and medical therapy. The aim of this study was to document the degree of consensus in the current management of perforated appendicitis in children. A survey was sent to all practicing pediatric surgeons in North America in April 2000 who were members of the American Pediatric Surgical Association for 1999-2000. Survey questions pertained to preoperative, perioperative, and postoperative practice patterns, particularly those issues related to use of antibiotic therapy. Among eligible surgeons, 80.2% completed the survey. Although more than 80% of respondents practiced in an academic setting, only 17% of surgeons used a formal clinical practice guideline to direct care. Responses varied substantially in the duration of postoperative antibiotic therapy, the use of intravenous or oral agents or both, and the duration of hospitalization. A considerable number of patients are receiving a portion of their intravenous antibiotic therapy as outpatients. There is little apparent consensus in the many aspects of perioperative and postoperative care of perforated appendicitis in children across North America. Only a fraction of surgeons currently uses a formal clinical practice guideline for treatment of perforated appendicitis, although increased pressures to develop more cost-effective therapeutic strategies can encourage development of additional guidelines. Definitive evidence to inform development of such guidelines and enhance consensus is lacking. Further studies are needed across institutions to better inform clinical decisions in light of a changing practice environment and treatment alternatives.

8:30 Implementation of clinical practice guidelines in workers compensation board patients with acute mechanical back pain: a prospective randomized trial

Purpose of study: The study objectives were to assess the degree to which the patterns of practice of primary care physicians in managing workers compensation board (WCB) patients are in compliance with current practice guidelines and determine whether providing family physicians and their patients with the guidelines would alter the degree of adherence.Methods used: A total of 724 patients with nonradicular lower back pain of less than 2 weeks duration and accepted WCB claims were randomized into five groups: Group 1, physicians received a single information package summarizing the guidelines for managing acute mechanical back pain at 0 to 4 weeks after injury; Group 2, physicians received the same package and, in addition, their patients received a layperson's summary of the guidelines at 0 to 4 weeks after injury; Group 3, physicians received the information package three times, at 0–4-week, 5–8-week and 8–12-week postinjury periods; Group 4, physicians and their patients received the information packages at the 0–4 week, 5–8 week and 8–12-week postinjury periods; Group 5, neither the physicians nor their patients received any guideline information (control group). The compulsory WCB physician report forms were collected and scored. The primary outcome was compliance with guideline recommendations regarding specific patient history items, physical examination procedures and treatment recommendations. The chi-squared test was used to compare the five groups.of findings: Primary care physicians in the control group demonstrated a high degree of compliance with the recommended history taking, physical examination procedures and imaging guidelines but were in poor compliance with the guideline-recommended treatments. Providing the physicians ± patients with a single information package (ie, Groups 1 and 2) did not result in any significant improvement in compliance. Information provided at three separate intervals (Group 3) improved compliance with some recommended treatments, such as exercise, medications, less use of bed rest and passive physiotherapy, but not others including recommendation for spinal manipulation, work modification and return to normal activity. No added benefit was observed when providing patients with an information package (Group 4).Relationship between findings and existing knowledge: In the last 8 years, 12 countries have published evidence-based guidelines to assist primary care physicians in the management of acute and chronic lower back pain. Despite this large international effort and high degree of agreement among independent multidisciplinary panels of experts, a number of studies have demonstrated that the implementation of the guidelines has been largely unsuccessful. No prior published studies have examined guideline implementation strategies in primary care physicians managing WCB patients. The results of this study provide convincing evidence that ignorance of the guidelines is not the only contributing factor in determining the patterns of practice of primary care physicians.Overall significance of findings: Providing physicians with information regarding clinical practice guidelines for the management of acute back pain at three stages of the patient's clinical course (ie, 0 to 4, 4 to 8 and 8 to 12 weeks after injury) altered some aspects of physician pattern of practice, but results were not ideal. Alternate strategies need to be developed for improving physician compliance with clinical practice guidelines for treatment of WCB patients with acute lower back pain.Disclosures: No disclosures.Conflict of interest: Dr. Paul Bishop, grant research support from the Workers Compensation Board of British Columbia.

The Development of Clinical Practice Guidelines for Treatment of Peptic Acid Diseases in a VA Ambulatory Care Clinic—Authors' Reply

The Development of Clinical Practice Guidelines for Treatment of Peptic Acid Diseases in a VA Ambulatory Care Clinic—Authors' Reply

The Development of Clinical Practice Guidelines for Treatment of Peptic Acid Diseases in a VA Ambulatory Care Clinic—A Comment

The Development of Clinical Practice Guidelines for Treatment of Peptic Acid Diseases in a VA Ambulatory Care Clinic—A Comment

American Nurses Association endorses clinical practice guidelines for treatment of pressure ulcers

American Nurses Association endorses clinical practice guidelines for treatment of pressure ulcers