Good Practice Points Research Articles

Evidence-based recommendations on automated external defibrillator training for children and young people in Flanders-Belgium

ObjectiveThe aim of the study was to identify the most relevant literature on skills, attitude and behaviour of children and young people towards the use of an automated external defibrillator (AED) and then develop recommendations according to the principles of evidence-based practice. These recommendations were to serve as a basis for educational materials which would ensure that the implementation of AED-training within schools and youth organisations would be a simple process. MethodsA systematic literature search was performed using a specific research question: “Are children of different ages able/willing to use an AED after a training compared to another/no training?”. A guideline development panel meeting was organised to formulate practice guidelines. The panel consisted of experts from different fields (medicine, education and psychology) and representatives of the end users (teachers and youth leaders). ResultsThe systematic literature search identified five studies concerning AED skills by children and young people, and two studies concerning the attitudes and behaviour of children and young people towards the use of an AED. The guideline development panel carefully examined the available scientific evidence, took into consideration the skills and attitudes of children and young people, including the psychological consequences of managing a potentially life-saving situation and formulated evidence-based recommendations and good practice points. ConclusionBased on these recommendations, an education programme and new educational materials have been developed by the Belgian Red Cross-Flanders. In this way school staff and youth leaders are properly supported to teach first aid techniques to children and young people (6–18 years).

Guidelines for a palliative approach for aged care in the community setting: A suite of resources

In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two 'plain English' booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.The resources are intended to facilitate home care that acknowledges and plans for the client's deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and clinically futile interventions are also minimised.

Épidémiologie et évaluation des procédures de limitation et d’arrêt des traitements de maintien des fonctions vitales en réanimation pédiatrique

ObjectivesLeonetti Law of 2005 concerns procedures for questioning about the appropriateness of initiating or maintaining life-sustaining treatments. Decision of withdrawing and withholding treatment has long been practiced by neonatologists, adult and pediatricians intensivists. In this regard, the recommendations of societies encourage medical teams to assess their practices to improve them. Our evaluation is based on the document of the Ethics Committee of SRLF edited in 2010. Type of studyWe achieved a retrospective evaluation of professional practices of the transcription of our decisions of withdrawing and withholding treatment. Patients and methodsThis study included all children (95 patients) who have had a questioning about life-sustaining treatment of ICU between March 2008 and August 2011 in the pediatric intensive care unit of Children's Hospital of Lyon. Our evaluation is based on the document of the Ethics Committee of French Society of intensive care (SRLF) edited in 2010. We collected epidemiological data on children concerned by questioning about the appropriateness of initiating or maintaining LST and an evaluation of the transcription of our procedures for LST in our folders. Evaluation included 40 cases: 20 folders randomly selected prior an information meeting (January 2011) which were compared with 20 cases occurred consecutively after this information. This meeting was intended to remind recommendations of good practice and principal points of the law. The main assessment measure was the improvement of the practices respecting criteria of the document of the Ethics Committee of SRLF modified for pediatric care. Main resultsEpidemiological data on procedures are comparable to literature data. Concerning the evaluation of our practices before/after a briefing and highlighted a tendency to the improvement without statistically significance. The transcription of reflection and the arguments of decision of withdrawing and withholding treatment and evaluation of pain was the points who need improvement. Finally, despite the positive developments in the therapeutic use of analgesics and sedatives, pain continues to be undervalued. ConclusionThe evaluation of professional practices is recommended to improve the procedures of questioning about life-sustaining treatments have become an area of expertise in intensive care.

Self-harm by children and young people: care and compassion

This article discusses self-harm by young people and highlights the role of the nurse in providing compassionate care. The views of young people about the services they receive following self-harm are discussed, and the complicated link between self-harm and suicide is explored. Some good practice points for assessment are included, and a summary of self-harm treatments is provided. Nurses are encouraged to consider their attitudes towards self-harm, and consider how they respond to young people who may be distressed and struggling.

EFNS task force: the use of neuroimaging in the diagnosis of dementia

The European Federation of the Neurological Societies (EFNS) guidelines on the use of neuroimaging in the diagnosis and management of dementia are designed to revise and expand previous EFNS recommendations for the diagnosis and management of patients with Alzheimer's disease (AD) and to provide an overview of the evidence for the use of neuroimaging techniques in non-AD dementias, as well as general recommendations that apply to all types of dementia in clinical practice. The task force working group reviewed evidence from original research articles, meta-analyses and systematic reviews, published before April 2012. The evidence was classified, and consensus recommendations were given and graded according to the EFNS guidance regulations. Structural imaging, which should be performed at least once in the diagnostic work-up of patients with cognitive impairment, serves to exclude other potentially treatable diseases, to recognize vascular lesions and to identify specific findings to help distinguish different forms of neurodegenerative types of dementia. Although typical cases of dementia may not benefit from routine functional imaging, these tools are recommended in those cases where diagnosis remains in doubt after clinical and structural imaging work-up and in particular clinical settings. Amyloid imaging is likely to find clinical utility in several fields, including the stratification of patients with mild cognitive impairment into those with and without underlying AD and the evaluation of atypical AD presentations. A number of recommendations and good practice points are made to improve the diagnosis of AD and other dementias.

EFNS‐ENS Guidelines on the diagnosis and management of disorders associated with dementia

The last version of the EFNS dementia guidelines is from 2007. In 2010, the revised guidelines for Alzheimer's disease (AD) were published. The current guidelines involve the revision of the dementia syndromes outside of AD, notably vascular cognitive impairment, frontotemporal lobar degeneration, dementia with Lewy bodies, corticobasal syndrome, progressive supranuclear palsy, Parkinson's disease dementia, Huntington's disease, prion diseases, normal-pressure hydrocephalus, limbic encephalitis and other toxic and metabolic disorders. The aim is to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists and other specialist physicians responsible for the care of patients with dementing disorders. It represents a statement of minimum desirable standards for practice guidance. The task force working group reviewed evidence from original research articles, meta-analyses and systematic reviews, published by June 2011. The evidence was classified (I, II, III, IV) and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided. New recommendations and good practice points are made for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers. All recommendations were revised as compared with the previous EFNS guidelines. The specialist neurologist together with primary care physicians play an important role in the assessment, interpretation and treatment of symptoms, disability and needs of dementia patients.

1.0 Introduction

1.0 Introduction

British Dietetic Association evidence‐based guidelines for the dietary management of irritable bowel syndrome in adults

Irritable bowel syndrome (IBS) is a chronic debilitating functional gastrointestinal disorder. Diet and lifestyle changes are important management strategies. The aim of these guidelines is to systematically review key aspects of the dietary management of IBS, with the aim of providing evidence-based guidelines for use by registered dietitians. Questions relating to diet and IBS symptom management were developed by a guideline development group. These included the role of milk and lactose, nonstarch polysaccharides (NSP), fermentable carbohydrates in abdominal bloating, probiotics and empirical or elimination diets. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines: Cinahl, Cochrane Library, Embase, Medline, Scopus and Web of Science. Evidence statements, recommendations, good practice points and research recommendations were developed. Thirty studies were critically appraised. A dietetic care pathway was produced following a logical sequence of treatment and formed the basis of these guidelines. Three lines of dietary management were identified. first line: Clinical and dietary assessment, healthy eating and lifestyle management with some general advice on lactose and NSP. Second line: Advanced dietary interventions to improve symptoms based on NSP, fermentable carbohydrates and probiotics. Third line: Elimination and empirical diets. Research recommendations were also identified relating to the need for adequately powered and well designed randomised controlled trials. These guidelines provide evidence-based details of how to achieve the successful dietary management of IBS.

Can We Always Rely on “Evidence-Based Medicine”?

Currently, the evidence-based medicine, EBM, has become essential in every field of medicine and many clinical guidelines have been developed based on the high-quality evidence. Such evidence has usually classified into 6 levels according to the quality of the studies. A meta-analysis of randomized controlled trials is considered as the highest level of evidence. The meta-analysis, however, has several pit-falls that we should keep in mind. The pit-falls are Simpson’s paradox, the selection bias, the publication bias, and the geographical bias. In the clinical setting of otolaryngology, it is not always possible to obtain a high level of evidence for conventional clinical treatments such as myringotomy, sinus puncture and aspiration, aeration of the Eustachian tube for the treatment of otitis media with effusion, and so on. Since these treatment modalities have no high-level of evidence, should we therefore stop performing them? No. We should have a further look at these treatments as “good practice points (GPP)”. Otolaryngological specialists should play an important role in combining high-quality evidence and GPP to seek the optimum treatment approach for each patient.

European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive Summary

The Clinical Guidelines provide an opportunity to summarise the interpretation of relevant clinical trial evidence for older people with diabetes. They are intended to support clinical decisions in older people with diabetes and the primary focus is enhancing high quality diabetes care by the use of best available evidence. The principles used for developing the recommendations are drawn from the Scottish Intercollegiate Guidelines Network (SIGN) based in Edinburgh, Scotland. Using SIGN 50, the Guidelines developer's handbook, each reviewer evaluated relevant and appropriate studies which have attempted to answer key clinical questions identified by the Working Party. Searches were generally limited to English language citations over the previous 15 years but the wide experience and multinational nature of the Working party ensured that citations in Italian, French Spanish, and German were considered if relevant. All relevant published articles were identified from the following databases: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 13 key major peer-reviewed journals was undertaken by two reviewers and included the Lancet, Diabetes, Diabetologia, Diabetes Care, Diabetes and Metabolism, British Medical Journal, New England Journal of Medicine, and the Journal of the American Medical Association. Key evidenced-based recommendations were made in 18 clinical domains of interest and Good Clinical Practice points identified. A glucose-lowering algorithm has been provided for frail older patients with diabetes. We have provided an up-to-date evidenced-based approach to practical clinical decision-making for older adults with type 2 diabetes of 70 years and over. We have included a user-friendly set of recommendations to aid clinical decision-making in primary, community-based and secondary care settings.

Corrigendum

European Journal of NeurologyVolume 18, Issue 5 p. 796-796 Free Access Corrigendum This article corrects the following: European Federation of Neurological Societies/Peripheral Nerve Society Guideline on management of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society — First Revision P. Y. K. Van den Bergh, R. D. M. Hadden, P. Bouche, D. R. Cornblath, A. Hahn, I. Illa, C. L. Koski, J.-M. Léger, E. Nobile-Orazio, J. Pollard, C. Sommer, P. A. Van Doorn, I. N. Van Schaik, Volume 17Issue 3European Journal of Neurology pages: 356-363 First Published online: February 23, 2010 First published: 15 April 2011 https://doi.org/10.1111/j.1468-1331.2011.03403.xCitations: 2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL In [1], the following error was published in Table 1 on page 358: 1(c) should read as ‘Prolongation of F-wave latency ≥20% above ULN in 2 nerves’ instead of ‘Prolongation of F-wave latency ≥30% above ULN in 2 nerves’. The corrected Table 1 is below. Table 1. Electrodiagnostic criteria (1) Definite: at least one of the following (a) Motor distal latency prolongation ≥50% above ULN in two nerves (excluding median neuropathy at the wrist from carpal tunnel syndrome), or (b) Reduction of motor conduction velocity ≥30% below LLN in two nerves, or (c) Prolongation of F-wave latency ≥20% above ULN in two nerves (≥50% if amplitude of distal negative peak CMAP <80% of LLN values), or (d) Absence of F-waves in two nerves if these nerves have distal negative peak CMAP amplitudes ≥20% of LLN + ≥1 other demyelinating parametera in ≥1 other nerve, or (e) Partial motor conduction block: ≥50% amplitude reduction of the proximal negative peak CMAP relative to distal, if distal negative peak CMAP ≥ 20% of LLN, in two nerves, or in one nerve + ≥1 other demyelinating parametera in ≥1 other nerve, or (f) Abnormal temporal dispersion (>30% duration increase between the proximal and distal negative peak CMAP) in ≥2 nerves, or (g) Distal CMAP duration (interval between onset of the first negative peak and return to baseline of the last negative peak) increase in ≥1 nerve (median ≥ 6.6 ms, ulnar ≥ 6.7 ms, peroneal ≥ 7.6 ms, tibial ≥ 8.8 ms)b + ≥1 other demyelinating parametera in ≥1 other nerve (2) Probable ≥30% amplitude reduction of the proximal negative peak CMAP relative to distal, excluding the posterior tibial nerve, if distal negative peak CMAP ≥ 20% of LLN, in two nerves, or in one nerve + ≥1 other demyelinating parametera in ≥1 other nerve (3) Possible As in (1) but in only one nerve To apply these criteria, the median, ulnar (stimulated below the elbow), peroneal (stimulated below the fibular head), and tibial nerves on one side are tested. If criteria are not fulfilled, the same nerves are tested at the other side, and/or the ulnar and median nerves are stimulated bilaterally at the axilla and at Erb’s point. Motor conduction block is not considered in the ulnar nerve across the elbow and at least 50% amplitude reduction between Erb’s point and the wrist is required for probable conduction block. Temperatures should be maintained to at least 33°C at the palm and 30°C at the external malleolus (good practice points). CMAP, compound muscle action potential; ULN, upper limit of normal values; LLN, lower limit of normal values. aAny nerve meeting any of the criteria (a–g). bIsose S. et al., in press [16]. We apologize for the error. Reference 1 Van den Bergh PYK, Hadden RDM, Bouche P, et al. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on management of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society — First Revision. Eur J Neurol 2010; 17: 356– 363. Citing Literature Volume18, Issue5May 2011Pages 796-796 ReferencesRelatedInformation

Screening for tumours in paraneoplastic syndromes: report of an EFNS Task Force

paraneoplastic neurological syndromes (PNS) almost invariably predate detection of the malignancy. Screening for tumours is important in PNS as the tumour directly affects prognosis and treatment and should be performed as soon as possible. an overview of the screening of tumours related to classical PNS is given. Small cell lung cancer, thymoma, breast cancer, ovarian carcinoma and teratoma and testicular tumours are described in relation to paraneoplastic limbic encephalitis, subacute sensory neuronopathy, subacute autonomic neuropathy, paraneoplastic cerebellar degeneration, paraneoplastic opsoclonus-myoclonus, Lambert-Eaton myasthenic syndrome (LEMS), myasthenia gravis and paraneoplastic peripheral nerve hyperexcitability. many studies with class IV evidence were available; one study reached level III evidence. No evidence-based recommendations grade A-C were possible, but good practice points were agreed by consensus. the nature of antibody, and to a lesser extent the clinical syndrome, determines the risk and type of an underlying malignancy. For screening of the thoracic region, a CT-thorax is recommended, which if negative is followed by fluorodeoxyglucose-positron emission tomography (FDG-PET). Breast cancer is screened for by mammography, followed by MRI. For the pelvic region, ultrasound (US) is the investigation of first choice followed by CT. Dermatomyositis patients should have CT-thorax/abdomen, US of the pelvic region and mammography in women, US of testes in men under 50 years and colonoscopy in men and women over 50. If primary screening is negative, repeat screening after 3-6 months and screen every 6 months up till 4 years. In LEMS, screening for 2 years is sufficient. In syndromes where only a subgroup of patients have a malignancy, tumour markers have additional value to predict a probable malignancy.

EFNS guidelines for the diagnosis and management of Alzheimer’s disease

In 2008 a task force was set up to develop a revision of the European Federation of the Neurological Societies (EFNS) guideline for the diagnosis and management of Alzheimer's disease (AD) and other disorders associated with dementia, published in early 2007. The aim of this revised international guideline was to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists, and other specialist physicians responsible for the care of patients with AD. Mild cognitive impairment and non-Alzheimer dementias are not included in this guideline. The task force working group reviewed evidence from original research articles, meta-analysis, and systematic reviews, published before May 2009. The evidence was classified and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided. The recommendations for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of AD, behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers were all revised as compared with the previous EFNS guideline. A number of new recommendations and good practice points are made, namely in CSF, neuropsychology, neuroimaging and reviewing non-evidence based therapies. The assessment, interpretation, and treatment of symptoms, disability, needs, and caregiver stress during the course of AD require the contribution of many different professionals. These professionals should adhere to these guideline to improve the diagnosis and management of AD.

European Federation of Neurological Societies/Peripheral Nerve Society Guideline* on management of paraproteinemic demyelinating neuropathies. Report of a Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society – first revision

The aim of this guideline is to update the 2006 EFNS/PNS guideline on management of patients with a demyelinating neuropathy and a paraprotein (paraproteinemic demyelinating neuropathy [PDN]) by review of evidence and expert consensus. In the absence of adequate evidence, the panel agreed on good practice points: (1) patients with PDN should be investigated for a malignant plasma cell dyscrasia; (2) a monoclonal gammopathy of undetermined significance is more likely to be causing the neuropathy if it is immunoglobulin (Ig)M, anti-neural antibodies are present, and the clinical phenotype is chronic distal sensory neuropathy; (3) patients with IgM PDN usually have predominantly distal sensory impairment, prolonged distal motor latencies, and often anti-myelin-associated glycoprotein antibodies; (4) IgM PDN may respond to immunomodulatory therapies. Their potential benefit should be balanced against possible side effects and the usually slow disease progression; (5) IgG and IgA PDN may be indistinguishable from chronic inflammatory demyelinating polyradiculoneuropathy; and (6) Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin changes syndrome is a multi-system malignant PDN.

Snapshots in time: using real‐time evaluations in humanitarian emergencies

PurposeThe paper's aim is to assess the usefulness of the real time evaluation methodology in rapid‐onset humanitarian emergencies and to document recurring constraints and lessons learned.Design/methodology/approachA small online survey was carried out among evaluation interviewees and a desk study was commissioned to extrapolate good practice and learning points from nine evaluations carried out by one international organisation over the past three years.FindingsGiven the changing nature of the environment in which agencies work during rapid onset humanitarian emergencies, impact evaluations are often carried out too late for important programme changes to be made. The real time evaluation methodology has proved to be a reliable and useful tool for process evaluation during rapid‐onset emergencies. However, it is clear, if it does not take place within the first two months the chances of programmatic changes being made are minimal. There is still the issue of organisational learning and ensuring that lessons learned from one response are taken forward in future programmes. Although there are several risks associated with the methodology, these are outweighed by the advantages, both immediate and longer‐term.Practical implicationsThe findings from these studies has been of value to the organisation but they are also of interest to the wider humanitarian sector struggling with the practicalities of process evaluations in a challenging environment.Originality/valueAlthough there are several publications about real time evaluation methodology, this paper is one of the first attempts by a non‐UN organisation to critically review evaluation reports and to document the staff opinions.

EFNS guideline on the treatment of tension‐type headache – Report of an EFNS task force

Tension-type headache (TTH) is the most prevalent headache type and is causing a high degree of disability. Treatment of frequent TTH is often difficult. To give evidence-based or expert recommendations for the different treatment procedures in TTH based on a literature search and the consensus of an expert panel. All available medical reference systems were screened for the range of clinical studies on TTH. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points. Non-drug management should always be considered although the scientific basis is limited. Information, reassurance and identification of trigger factors may be rewarding. Electromyography (EMG) biofeedback has a documented effect in TTH, whilst cognitive-behavioural therapy and relaxation training most likely are effective. Physical therapy and acupuncture may be valuable options for patients with frequent TTH, but there is no robust scientific evidence for efficacy. Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for the treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice for the prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are drugs of second choice. The efficacy of the prophylactic drugs is often limited, and treatment may be hampered by side effects.

EFNS guidelines on the molecular diagnosis of channelopathies, epilepsies, migraine, stroke, and dementias

These EFNS guidelines on the molecular diagnosis of channelopathies, including epilepsy and migraine, as well as stroke, and dementia are designed to summarize the possibilities and limitations of molecular genetic techniques and to provide diagnostic criteria for deciding when a molecular diagnostic work-up is indicated. To collect data about planning, conditions, and performance of molecular diagnosis of these disorders, a literature search in various electronic databases was carried out and original papers, meta-analyses, review papers, and guideline recommendations were reviewed. The best level of evidence for genetic testing recommendation (B) can be found for a small number of syndromes, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, severe myoclonic epilepsy of infancy, familial recurrent hemorrhages, familial Alzheimer's disease, and frontotemporal lobar degeneration. Good practice points can be formulated for a number of other disorders. These guidelines are provisional, and the future availability of molecular genetic epidemiological data about the neurogenetic disorders under discussion in our article will allow improved recommendation with an increased level of evidence.

EFNS guideline on the management of status epilepticus in adults

The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4-8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non-anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.

EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis

Lyme neuroborreliosis (LNB) is a nervous system infection caused by Borrelia burgdorferi sensu lato (Bb). To present evidence-based recommendations for diagnosis and treatment. Data were analysed according to levels of evidence as suggested by EFNS. The following three criteria should be fulfilled for definite LNB, and two of them for possible LNB: (i) neurological symptoms; (ii) cerebrospinal fluid (CSF) pleocytosis; (iii) Bb-specific antibodies produced intrathecally. PCR and CSF culture may be corroborative if symptom duration is <6 weeks, when Bb antibodies may be absent. PCR is otherwise not recommended. There is also not enough evidence to recommend the following tests for diagnostic purposes: microscope-based assays, chemokine CXCL13, antigen detection, immune complexes, lymphocyte transformation test, cyst formation, lymphocyte markers. Adult patients with definite or possible acute LNB (symptom duration <6 months) should be offered a single 14-day course of antibiotic treatment. Oral doxycycline (200 mg daily) and intravenous (IV) ceftriaxone (2 g daily) are equally effective in patients with symptoms confined to the peripheral nervous system, including meningitis (level A). Patients with CNS manifestations should be treated with IV ceftriaxone (2 g daily) for 14 days and late LNB (symptom duration >6 months) for 3 weeks (good practice points). Children should be treated as adults, except that doxycycline is contraindicated under 8 years of age (nine in some countries). If symptoms persist for more than 6 months after standard treatment, the condition is often termed post-Lyme disease syndrome (PLDS). Antibiotic therapy has no impact on PLDS (level A).

FP51-TH-05 Good clinical practice points on the use of acetylcholinesterase inhibitors in myasthenia gravis: recommendations from a South-East Asian regional special interest group on myasthenia gravis

FP51-TH-05 Good clinical practice points on the use of acetylcholinesterase inhibitors in myasthenia gravis: recommendations from a South-East Asian regional special interest group on myasthenia gravis