Development Of Evidence-based Recommendations Research Articles

AARC Clinical Practice Guidelines: Artificial Airway Suctioning.

Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.

Organic acidurias: Major gaps, new challenges, and a yet unfulfilled promise.

Organic acidurias (OADs) comprise a biochemically defined group of inherited metabolic diseases. Increasing awareness, reliable diagnostic work-up, newborn screening programs for some OADs, optimized neonatal and intensive care, and the development of evidence-based recommendations have improved neonatal survival and short-term outcome of affected individuals. However, chronic progression of organ dysfunction in an aging patient population cannot be reliably prevented with traditional therapeutic measures. Evidence is increasing that disease progression might be best explained by mitochondrial dysfunction. Previous studies have demonstrated that some toxic metabolites target mitochondrial proteins inducing synergistic bioenergetic impairment. Although these potentially reversible mechanisms help to understand the development of acute metabolic decompensations during catabolic state, they currently cannot completely explain disease progression with age. Recent studies identified unbalanced autophagy as a novel mechanism in the renal pathology of methylmalonic aciduria, resulting in impaired quality control of organelles, mitochondrial aging and, subsequently, progressive organ dysfunction. In addition, the discovery of post-translational short-chain lysine acylation of histones and mitochondrial enzymes helps to understand how intracellular key metabolites modulate gene expression and enzyme function. While acylation is considered an important mechanism for metabolic adaptation, the chronic accumulation of potential substrates of short-chain lysine acylation in inherited metabolic diseases might exert the opposite effect, in the long run. Recently, changed glutarylation patterns of mitochondrial proteins have been demonstrated in glutaric aciduria type 1. These new insights might bridge the gap between natural history and pathophysiology in OADs, and their exploitation for the development of targeted therapies seems promising.

Уголовно-правовое значение причин и условий в сфере небезопасного выполнения строительных работ

Modern society has one of its characteristics the development of the service sector. At the same time, the level of development of the sphere of performance of works and rendering of services is defined rather with prevalence, but at all with observance of necessary rules and requirements of safety. Due to the priority of the intensity of production by the performers of works and services, certain rules and safety requirements are often ignored, which in any case creates the risk of occurrence of certain negative consequences. The legal structure of the corpus delicti provided for in article 216 of the criminal code obliges the law enforcer to establish not only the fact of violation of safety rules during construction works and the fact of occurrence of socially dangerous consequences in the form of causing serious harm to human health or major damage, but also the presence of a causal relationship between these phenomena to bring the guilty person to criminal responsibility. The work is devoted to the development of evidence-based recommendations for resolving law enforcement issues related to the assessment of the causal complex in the unsafe conduct of construction works. To achieve this goal, the current criminal legislation, explanations of the Plenum of the Supreme Court of the Russian Federation, materials of judicial and investigative practice, as well as scientific works affecting the theme of the work are analyzed. The methodological basis consists of General scientific provisions of philosophy, logic and other Sciences, dialectical, formal-logical, hypothetical, linguistic methods, a special place in the study took methods such as analysis and synthesis, induction and deduction. Proposals to improve law enforcement in terms of assessing the role of causes and conditions in the legal assessment of socially dangerous acts under article 216 of the criminal code are formulated.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

BackgroundExisting physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).MethodsThe PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.ResultsThe German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.ConclusionThe development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

An outbreak of Norovirus infections associated with recreational lake water in Western Finland, 2014.

In July 2014, an outbreak of gastroenteritis occurred among visitors to lakes in Tampere, Finland. We conducted a retrospective cohort study using an internet-based survey, solicited by public announcement, to identify source of infection and to implement control measures. Of 1453 persons enrolled in the study, 244 met the case definition (attack rate, 17%). In the pooled univariate analysis, risk factors for gastroenteritis included getting water in the mouth while swimming (Risk ratio (RR) 3.32; 95% Confidence interval (CI), 2.36-4.68) and playing on the wet sand at the beach (RR 1.90; 95% CI 1.50-2.41). In a multivariable analysis (logistic regression), the source of the infection was likely at two lakes (lake A Odds ratio (OR) 1.66; 95% CI 1.15-2.39 and lake B, OR 2.35; 95% CI 1.49-3.72). Norovirus (NoV) was found in 19 stool samples. All water samples from implicated beaches had acceptable values of fecal indicator bacteria and were negative for NoV. The likely source of the outbreak was lake-water contaminated with NoV at two popular lakes. Closure of swimming beaches, advice on hygienic precautions and rapid outbreak alerts were efficient in controlling the outbreak. Results suggest a need for new indicators of water quality and development of evidence-based recommendations regarding timing of safe reopen of recreational water venues associated with outbreaks.

The development of evidence-based recommendations for supporting informal carers of people living with Motor Neurone Disease

The development of evidence-based recommendations for supporting informal carers of people living with Motor Neurone Disease

Development of Evidence-based Recommendations: Implications for Preparing Expert Consensus Statements.

Development of Evidence-based Recommendations: Implications for Preparing Expert Consensus Statements.

Perspective and priorities for improvement of parathyroid hormone (PTH) measurement – A view from the IFCC Working Group for PTH

Parathyroid hormone (PTH) measurement in serum or plasma is a necessary tool for the exploration of calcium/phosphate disorders, and is widely used as a surrogate marker to assess skeletal and mineral disorders associated with chronic kidney disease (CKD), referred to as CKD-bone mineral disorders (CKD-MBD). CKD currently affects >10% of the adult population in the United States and represents a major health issue worldwide. Disturbances in mineral metabolism and fractures in CKD patients are associated with increased morbidity and mortality. Appropriate identification and management of CKD-MBD is therefore critical to improving clinical outcome.Recent increases in understanding of the complex pathophysiology of CKD, which involves calcium, phosphate and magnesium balance, and is also influenced by vitamin D status and fibroblast growth factor (FGF)-23 production, should facilitate such improvement. Development of evidence-based recommendations about how best to use PTH is limited by considerable method-related variation in results, of up to 5-fold, as well as by lack of clarity about which PTH metabolites these methods recognise. This makes it difficult to compare PTH results from different studies and to develop common reference intervals and/or decision levels for treatment. The implications of these method-related differences for current clinical practice are reviewed here. Work being undertaken by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) to improve the comparability of PTH measurements worldwide is also described.

I70 Development of Evidence-Based Recommendations for Diagnosis, Assessment and Treatment of Lupus

I70 Development of Evidence-Based Recommendations for Diagnosis, Assessment and Treatment of Lupus

Do Cochrane systematic reviews meet WHO needs?

Keywords: Cochrane reviews; GRADE methodology; implementation; observational studies; randomized clinical trials; WHO guidelines

Swedish general practitioners' attitudes towards treatment guidelines - a qualitative study.

BackgroundDrug therapy in primary care is a challenge for general practitioners (GPs) and the prescribing decision is influenced by several factors. GPs obtain drug information in different ways, from evidence-based sources, their own or others’ experiences, or interactions with opinion makers, patients or colleagues. The need for objective drug information sources instead of drug industry-provided information has led to the establishment of local drug and therapeutic committees. They annually produce and implement local treatment guidelines in order to promote rational drug use. This study describes Swedish GPs’ attitudes towards locally developed evidence-based treatment guidelines.MethodsThree focus group interviews were performed with a total of 17 GPs working at both public and private primary health care centres in Skåne in southern Sweden. Transcripts were analysed by conventional content analysis. Codes, categories and themes were derived from data during the analysis.ResultsWe found two main themes: GP-related influencing factors and External influencing factors. The first theme emerged when we put together four main categories: Expectations and perceptions about existing local guidelines, Knowledge about evidence-based prescribing, Trust in development of guidelines, and Beliefs about adherence to guidelines. The second theme included the categories Patient-related aspects, Drug industry-related aspects, and Health economic aspects. The time-saving aspect, trust in evidence-based market-neutral guidelines and patient safety were described as key motivating factors for adherence. Patient safety was reported to be more important than adherence to guidelines or maintaining a good patient-doctor relationship. Cost containment was perceived both as a motivating factor and a barrier for adherence to guidelines. GPs expressed concerns about difficulties with adherence to guidelines when managing patients with drugs from other prescribers. GPs experienced a lack of time to self-inform and difficulties managing direct-to-consumer drug industry information.ConclusionsPatient safety, trust in development of evidence-based recommendations, the patient-doctor encounter and cost containment were found to be key factors in GPs’ prescribing. Future studies should explore the need for transparency in forming and implementing guidelines, which might potentially increase adherence to evidence-based treatment guidelines in primary care.

Recommendations for the use of opioids in Brazil: Part II. Use in children and the elderly

JUSTIFICATIVA E OBJETIVOS: O tratamento da dor nos extremos de idade e na criança ainda exige atenção e revisão de paradigmas. Inúmeras são as doenças ou procedimentos que provocam dor desde o período neonatal até a adolescência. Nos idosos, há maior prevalência de doenças degenerativas que cursam com dor aguda e crônica. O objetivo deste estudo foi discutir recomendações para o emprego de opioides no neonato, na criança e no idoso. CONTEÚDO: Nesta revisão foi abordado o emprego de opioides no período neonatal, em crianças maiores e nos idosos, suas indicações, fármacos usados, doses, riscos, complicações e recomendações. CONCLUSÃO: O emprego de opioides em extremos de idade ainda é um desafio. No entanto, é necessária a educação continuada em torno do tema, estimulando a pesquisa clínica e a construção de recomendações baseadas em evidências. O uso seguro desses agentes na indicação e proporção corretas para o alívio da dor diminui riscos e deve ser a base da boa conduta clínica.

Immunization status of children with HIV: failure to protect a vulnerable population

The Children's HIV Association (http://www.chiva.org.uk/health/guidelines/immunisation; accessed 22 September 2009) and the Department of Health (http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook; accessed 17 September 2009) strongly recommend that HIV-positive children should receive all routine childhood immunizations. Exceptions are Bacillus Calmette–Guérin (BCG), regardless of CD4 cell count, and measles, mumps and rubella (MMR), if the CD4 cell count is <15% of total lymphocytes. HIV-infected children are at an increased risk of vaccine-preventable diseases. While we acknowledge that some vaccines are less effective in severely immunocompromised children [1], even on highly active antiretroviral therapy (HAART), we believe that efforts should be made to ensure immunization according to published UK guidelines. The aim was to audit the immunization status of HIV-positive children in London. A standardized proforma was used to collect data from children/adolescents attending four paediatric HIV clinics in 2008 (three tertiary level and one secondary level). Data were collected on routine and nonroutine vaccines from clinical notes and supplemented with information from Parent-Held Child Healthcare Records (‘Red Book’) and Primary Care records. Vaccination details supplied by parents, however seldom, were taken into account. Data were collected on 75 children. Fifty-five per cent were UK-born. The median age was 11 years (range 11 months to 20 years). The median CD4 percentage was 26% (range 4–47%) and the median viral load was 185 HIV-1 RNA copies/mL (range 0–2.4 × 105 copies/mL). Although children attended specialist clinics, only 5% had complete documentation of immunization in the medical notes. ‘Complete’ vaccination was determined on the basis of UK guidelines and accounted for age, vaccination history, contraindications, birth country and age of moving to the UK. Figure 1 shows proportions of children fully immunized with primary and booster doses of routine vaccines. Overall, 63% (186 of 297) of primary immunizations and only 41% (61 of 149) of booster immunizations were complete in children eligible to receive the vaccine (P<0.001). Sixty-one per cent (162 of 267) of all immunizations were complete in UK-born children compared with 47% (85 of 179) in non-UK-born children (P=0.006). Proportion of children fully immunized with routine vaccines. Nonroutine vaccinations in the UK include Bacillus Calmette–Guérin (BCG) for tuberculosis and hepatitis B. DTP, diphtheria, tetanus and pertussis; Hib, Haemophilus influenzae type b; Men C, meningococcal group C; MMR, measles, mumps and rubella; PCV, pneumococcal conjugate vaccine. Even though rates of immunization in London are lower than in the UK overall [e.g. 83% vs. 93% completed primary diphtheria, tetanus and pertussis (DTP) by age 5 years (http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/immunisation; accessed 3 September 2009)], rates in HIV-infected children were surprisingly low. HIV-infected children may have other risk factors for incomplete immunization such as residence in disadvantaged areas, history of hospital admission [2] or coming from an immigrant family. Childhood vaccinations are free; however, specialist clinics incur costs if vaccinations are provided through them, and not all have the funding or resources to do so. Additionally, guidelines are based on limited evidence in HIV-infected children, especially those with severe immune deficiency, causing uncertainty as to optimal practice. Approximately 20% of HIV-infected children nationally have a CD4% <20 (http://www.chipscohort.ac.uk/summary_data.asp; accessed 8 July 2010). This may contribute to the incomplete coverage observed for MMR in our study. Few studies have assessed the immunization status of HIV-infected children in industrialized countries. Like ours, recent Swiss and Spanish studies found lower immunization coverage in this population than in the general public [3,4]. A study from Texas found no difference between HIV-infected patients and the general population for diphtheria, tetanus, acellular pertussis and inactivated polio vaccine (DTaP-IPV) and MMR, although vaccine coverage was low overall [5]. We conclude that immunization of HIV-infected children is suboptimal in this London population. Booster doses and nonroutine vaccines are most commonly omitted. Immigrant children are particularly likely to be under-immunized. As life expectancy and the proportion of immigrant HIV-infected children increase, appropriate routine and catch-up immunization becomes more important. Development of evidence-based recommendations and standards for immunization of HIV-infected children, improved accessibility of immunization records, and opportunistic immunization in clinics may all improve this situation.

Methods For Evidence Synthesis in Interventional Pain Management

Healthcare decisions are increasingly being made on research-based evidence, rather than on expert opinion or clinical experience alone. Consequently, the process by which the strength of scientific evidence is evaluated and developed by means of evidence-based medicine recommendations and guidelines has become crucial resulting in the past decade in unprecedented interest in evidence-based medicine and clinical practice guidelines. Systematic reviews, also known as evidence-based technology assessments, attempt to minimize bias by the comprehensiveness and reproducibility of the search for and selection of articles for review. Evidence-based medicine is defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. Thus, the practice of evidence-based medicine requires the integration of individual clinical expertise with the best available external evidence from systematic research. To arrive at evidence-based medicine decisions all valid and relevant evidence should be considered alongside randomized controlled trials, patient preferences and resources. However, many systematic reviews in interventional pain management fail to follow evidence-based medicine principles. Clinical practice guidelines are systematically developed statements that assist clinicians, consumers and policy makers to make appropriate healthcare decisions. The complex processes of guideline development depend on integration of a number of activities, from collection and processing of scientific literature to evaluation of the evidence, development of evidence-based recommendations or guidelines and implementation and dissemination of the guidelines to relevant professionals and consumers. Guidelines are being designed to improve the quality of healthcare and decrease the use of unnecessary, ineffective or harmful interventions. This review describes various aspects of evidence-based medicine, systematic reviews in interventional pain management, evaluation of the strength of scientific evidence, differences between systematic and narrative reviews, rating the quality of individual articles, grading the strength of the body of evidence and appropriate methods for searching for the evidence.