Published Practice Guidelines Research Articles

Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm.

Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting. Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial.

Medical Physics Practice Guideline 4.a: Development, implementation, use and maintenance of safety checklists.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.The following terms are used in the AAPM practice guidelines: Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

AAPM Medical Physics Practice Guideline 3.a: Levels of supervision for medical physicists in clinical training.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.The following terms are used in the AAPM practice guidelines: Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Trends in incident hemodialysis access and mortality.

Based on evidence of survival benefit when initiating hemodialysis (HD) via arteriovenous fistula (AVF) or arteriovenous graft (AVG) vs hemodialysis catheter (HC), the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative published practice guidelines in 1997 recommending 50% or greater AVF rates in incident HD patients. A decade after, lapses exist and the impact on HD outcomes is uncertain. To assess the achievement of the practice goals for incident vascular access and the effects on HD outcomes. This retrospective cohort study was conducted using the US Renal Data System. All patients with end-stage renal disease in the United States without prior renal replacement therapy who had incident vascular access for HD created between January 1, 2006, and December 31, 2010 (N = 510 000) were included. Incident vascular access use rates and mortality. Relative mortality was quantified using multivariable Cox proportional hazard models. Coarsened exact matching and propensity score-matching techniques were used to better account for confounding by indication. Of 510 000 patients included in this study, 82.6% initiated HD via HC, 14.0% via AVF, and 3.4% via AVG. Arteriovenous fistula use increased only minimally, from 12.2% in 2006 to 15.0% in 2010. Patients initiating HD with AVF had 35% lower mortality than those with HC (adjusted hazard ratio, 0.65; 95% CI, 0.64-0.66; P < .001). Those initiating HD with AVF had 23% lower mortality than those initiating with an HC while awaiting maturation of an AVF (adjusted hazard ratio, 0.77; 95% CI, 0.76-0.79; P < .001). Current incident AVF practice falls exceedingly short years after recommendations were made in 1997. The impact of this shortcoming on mortality for patients with end-stage renal disease is enormous. Functioning permanent access at initiation of HD confers lower mortality even compared with patients temporized with an HC while awaiting maturation of permanent access. A change of current policies and structured multidisciplinary efforts are required to establish matured fistulae prior to HD to ameliorate this deficit in delivering care.

Educating other practitioners on how to assess menopausal women

Background:Despitemore than 1 in 4 postmenopausal women experiencing moderate to severe vasomotor symptoms, the use of hormone therapy is low. Presently less than 6% of Australian women are using hormone therapy and less than 1% are using prescription non-hormonal therapy to manage their symptoms [1]. Primary care physicians are uncertain not only about the risks and benefits of prescription hormonal and non-hormonal therapy, but also what to prescribe. Methods: We reviewed the published practice guidelines and position statements pertaining to management of the menopause, and studies of hormonal and non-hormonal therapies. Results: The “Practitioner Toolkit forManaging theMenopause” consists of simple algorithms that address: why a woman might present, who to determinemenopausal status without doing blood tests, key information that should be ascertained, issues that may influence treatment decisionmaking, hormonal and non hormonal treatment options, symptommanagement and patient review, and a brief supporting document. Conclusion: These algorithms and the supporting document provide an accessible desk-top tool for health care practitioners caring for women atmidlife. The toolkit has been published on line by the journal Climacteric and canbe accessed in full at the journal’s website.

Anticipated Difficult Airway in Ear, Nose and Throat Procedures

ABSTRACT Contrary to general and obstetric populations, where difficult airway is widely studied and well documented, it requires further research in elective and emergency ear, nose and throat (ENT) surgeries. American Society of Anesthesiologists (ASA) has published practice guidelines for the management of difficult airway, which help us deal with it perioperatively. All patients posted for ENT surgeries with difficult airway should be evaluated preoperatively and the strategy for management of difficult intubation as well as extubation chalked out. In the event, that the primary approach fails, the secondary plan should always be clear preoperatively, to reduce morbidity and mortality. How to cite this article Baldwa NM. Anticipated Difficult Airway in Ear, Nose and Throat Procedures. Int J Otorhinolaryngol Clin 2015;7(1):10-16.

Optimal blood pressure targets in 2014 – Does the guideline recommendation match the evidence base?

Various scientific societies have recently published practice guidelines for the diagnosis and management of arterial hypertension with no clear consensus on a blood pressure target. This article reviews those recommendations and critically examines if they are based on sound evidence.

ED-15 * LONG-TERM PROPHYLACTIC ANTIEPILEPTIC DRUGS USE IN PATIENTS WITH GLIOMAS: A 7 YEAR RETROSPECTIVE ANALYSIS IN A TERTIARY CARE CENTER

BACKGROUND: American Academy of Neurology's 2000 practice parameter do not support routine use of prophylactic antiepileptic drugs (AEDs) in newly diagnosed brain tumors. If used in the perioperative setting, they should be discontinued after the first postoperative week. However, it remains unclear whether such recommendations are followed. OBJECTIVE: To compare our use of long-term prophylactic AEDs in patients with gliomas to published practice guidelines by the AAN. METHODS: A retrospective chart review was performed on 578 glioma cases evaluated in a single tertiary care center from 2006-2013. Data collected included demographic factors, surgical procedure and tumor characteristics. Seizures and AED use were assessed at surgery, 3 months post-operatively and death/last visit/16 months. Long-term prophylactic AED use was defined as continued use of AED at 3 months post-surgery in the absence of seizures. Patients were divided into three groups at surgery: seizure-free with and without prophylactic AEDs, and seizure-patients. Survival, prophylaxis efficacy and factors influencing its use were calculated. RESULTS: Out of 578 patients operated between 2006-2013, 330(57.1%) were seizure-naive pre-operatively. 205/330(62.1%) received prophylactic AED at surgery. 96/205(46.9%) 95%CI(40.2-54.7) were still on AED 3 months post-surgery (median use = 58 days; 95%CI(31-152)). Rate of long-term prophylaxis use decreased by 13.5% over 6 years (70.3%-2006;56.8%-2012). Dilantin was the preferred agent in 2006(98.2%) with increasing use of Keppra over the years (44.6%-2012). There were no significant differences in age, histology, localisation and resected status between the seizure-free populations with and without prophylaxis. However, seizure-population had more men (p = 0.0068), younger patients (p < 0.0001), lower-grade gliomas (p = 0.0003) and lived longer (p = 0.0012,HR = 0.5423,95%CI(0.3742, 0.7859)) compared to seizure-free populations. The only predictive factor for prophylactic AEDs use was complete resection (p = 0.0069,OR = 2.0292,95%CI(1.2202, 3.4177)). Prevalence of first seizure was similar in both seizure-free populations (p = 0.9104, HR = 0.9627, 95%CI(0.5153, 1.806)). CONCLUSIONS: In our centre, long-term prophylactic AED use is high, deviating from current AAN Guidelines. Corrective measures are warranted.

A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management.

Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

Treatment Trends and Outcomes in US Hospital Stays of Children With Empyema

Recently published practice guidelines continue to reflect uncertainty about the comparative effectiveness of various treatments for empyema in children. We describe treatment trends and outcomes in pediatric empyema using the most current nationally representative data. Using survey methods and Kids' Inpatient Databases from 1997 to 2009, we evaluated hospital stays in children 0-18 years of age. We used 2009 data to compare transfer-out rates and lengths of stay across various types of treatment, after adjusting for patient and hospital factors. From 1997 to 2009, empyema discharges steadily increased from 3.1 to 6.0 per 100,000 children (P < 0.001 for trend) and also were increasingly likely (P < 0.01) to be coded for: (1) at least 1 pleural drainage procedure (76.4-83.2%), (2) multiple drainage procedures (36.0-41.6%) and (3) home health care (8.7-15.0%). By 2009, video-assisted thoracoscopic surgery was more commonly coded than chest tube drainage and was associated with a lower transfer-out rate (0.6% vs. 10.1%, adjusted P < 0.001) but no reduction in mean length of stay [11.2 vs. 13.4 days, adjusted incidence rate ratio 0.95 (95% confidence interval: 0.88-1.04)] for children neither admitted nor discharged by transfer. US hospital stays for empyema in children not only continued to increase through 2009 but were also characterized by more intense procedural management. Outcomes results in this population-based study are consistent with practice guidelines and recommendations that recently endorsed chest tube drainage as an acceptable first treatment option for most children with empyema.

Evaluation of a tailored implementation strategy to improve the management of patients with chronic obstructive pulmonary disease in primary care: a study protocol of a cluster randomized trial

BackgroundChronic obstructive pulmonary disease (COPD) remains a major health problem, strongly related to smoking. Despite the publication of practice guidelines on prevention and treatment, not all patients with the disease receive the recommended healthcare, particularly with regard to smoking cessation advice where applicable. We have developed a tailored implementation strategy for enhancing general practitioners’ adherence to the disease management guidelines. The primary aim of the study is to evaluate the effects of this tailored implementation intervention on general practitioners’ adherence to guidelines.Methods/DesignA pragmatic two-arm cluster randomized trial has been planned to compare care following the implementation of tailored interventions of four recommendations in COPD patients against usual care. The study will involve 18 general practices (9 in the intervention group and 9 in the control group) in Poland, each with at least 80 identified (at the baseline) patients with diagnosed COPD. The nine control practices will provide usual care without any interventions. Tailored interventions to implement four recommendations will be delivered in the remaining nine practices. At follow-up after nine months, data will be collected for all 18 general practices. The primary outcome measure is physicians’ adherence to all four recommendations: brief anti-smoking advice, dyspnea assessment, care checklist utilization and demonstration to patients of correct inhaler use. This measurement will be based on data extracted from identified patients’ records. Additionally, we will survey and interview patients with chronic obstructive pulmonary disease about the process of care.DiscussionThe results of this trial will be directly applicable to primary care in Poland and add to the growing body of evidence on interventions to improve chronic illness care.Trial registrationThis trial has been registered with Clinical Trials Protocol Registration System. Trial number: NCT01893476.

Avis critique sur la place du lithium dans les recommandations professionnelles sur la prise en charge du trouble bipolaire

ObjectivesIn the last few decades, from the discovery of lithium, an increasing number of drugs have been approved for the treatment of bipolar disorders. Guidelines have been established to help clinicians make a relevant choice of medication in specific clinical circumstances. The aim of this article is to review the place of lithium in the recent guidelines for the treatment of bipolar disorder. Materials and methodsWe reviewed the recently published guidelines in English and in French for the management of bipolar disorder. Electronic library and Web-based searches were performed using recognized tools (MEDLINE, PubMED and EMBASE) to identify guidelines that have been published since 2006. In addition, other sources of information known to us, such as national agency reports, were searched. ResultsSince 2006, seven sets of guidelines have been established or updated by official scientific societies. The different guidelines are in agreement on the choice of lithium to be used as a first-line treatment for mania. The efficacy of lithium in combination with second-generation antipsychotic in the management of manic episodes has made these associations first-line choices in some guidelines. However, choosing a combination from the outset for the management of mania will depend on whether the Task Force that developed the guidelines gives priority to efficacy or tolerance and not on the guidelines methodology, which is used. For the treatment of bipolar depressive episode, the only drug recommended in monotherapy as first-line treatment by all guidelines is quetiapine. The place of lithium in this indication is controversial and only some guidelines recommend lithium in monotherapy as first-line strategy. The recommendation grade of lithium depends on how the results of the studies are interpreted by the Task Force elaborating the guideline. Guidelines disagree on the first-line treatment choice in mixed state. Some guidelines make no distinction between treatments of classic mania and that of mixed state. The other guidelines consider lithium to be less efficacious in this indication. For the long-term treatment, all guidelines take into consideration the predominant mood polarity of the patient. Lithium is considered to have an important role in preventive strategies for bipolar disorder whatever the predominant mood polarity. However, it is perceived as a more effective treatment in the prevention of manic episodes than depressive episodes. ConclusionsLithium remains a gold standard treatment in the recently published practice guidelines. The main differences between the guidelines on its use are related to methodological discrepancies and interpretation of the scientific data by the Task Force that developed the guidelines.

Recommendations for organization of care for adults with congenital heart disease and for training in the subspecialty of ‘Grown-up Congenital Heart Disease’ in Europe: a position paper of the Working Group on Grown-up Congenital Heart Disease of the European Society of Cardiology

The European Society of Cardiology (ESC) has recently published practice guidelines for the management of grown-up congenital heart disease (GUCH).1 For the sake of space, this document did not include recommendations for the organization of care for adults with congenital heart disease (CHD) nor for training in the subspecialty of adult CHD, although emphasis was given to their importance and the need for a separate recommendations paper in the future.1 This publication is a position paper from the ESC Working Group on Grown-up Congenital Heart Disease, which makes recommendations for the standards and organization of care for adults with CHD, as well as for training in GUCH within Europe. Obviously, there is a lack of solid scientific data to support such recommendations and the majority of them must remain based on expert consensus. The remarkable improvement in survival of surgically and interventionally treated patients with CHD has led to an increasing number of GUCH patients, in particular those with more complex disease. There are also patients with newly diagnosed CHD lesions in adulthood such as atrial septal defect, coarctation of the aorta, Ebstein's anomaly and congenitally corrected transposition of the great arteries. The 32nd Bethesda Conference report in 20012 estimated that there were ∼2800 adults with CHD/million population, with more than half having moderate or highly complex disease. More recently, Marelli et al .3 reported a prevalence of 4090/million adults in Quebec for the year 2000 with 380 having severe disease. In Europe, we are currently faced with an estimated GUCH patient population of ∼2.3 million, which significantly outnumbers the paediatric CHD population of ∼1.9 million patients.4 There is general agreement that GUCH patients have very special needs and therefore physicians responsible of their care need specific expertise and training.1–11 It is …

AAPM Medical Physics Practice Guideline 2.a: Commissioning and quality assurance of X-ray-based image-guided radiotherapy systems.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.

Prenatal Detection of Congenital Heart Disease: Time for a Breakthrough

To borrow Churchill’s 1939 description of Russia, fetal wellbeing ever since man’s creation was a ‘‘riddle, wrapped in a mystery, inside an enigma’’ till the advent of medical ultrasonography. We are now able to identify with increasing accuracy the intricacies of cardiac pathology; however, the rates of prenatal detection of congenital heart disease (CHD), the most common type of birth defects in humans, continue to be suboptimal at best. The reported rates have been quite disappointing, ranging between 15 and 48 % with most being reported to be less than 30 % [4, 6, 9]. Even more recently, two published retrospective studies in high-risk populations at four major United States tertiary care centers, which take into account the use of more advanced technology and equipment, reported rates of detection of 24–36 % [5, 8]. This obviously continues to emphasize the poor prenatal detection rate and to stress the need for further improvement in this area. This year, the American Institute of Ultrasound in Medicine (AIUM), in conjunction with the American College of Radiology (ACR), the American College of Obstetricians and Gynecologists (ACOG) and the Society of Radiologists in Ultrasound (SRU), published the revised practice guidelines for the performance of Obstetric Ultrasound Examinations [1]. These guidelines, like those previously published, include essential minimal or mandatory elements as part of the standard ultrasound examination of fetal anatomy during the secondand thirdtrimester scan. Unlike the previous guidelines, however, this year’s publication includes a major change in screening the fetal heart in low risk pregnancies. The previous guidelines state that a basic cardiac examination should include a 4-chamber view of the fetal heart and, only when ‘‘technically feasible’’, views of the outflow tracts. The current guidelines, finally, clearly emphasize the inclusion of both the right and left outflow tracts view in addition to the 4-chamber view as an integral part of the minimal elements of the ultrasonographic assessment of the fetal heart. This significant change comes after various studies demonstrated the importance of adding the outflow tracts view to the routine prenatal screening ultrasound in addition to the four-chamber view. This has been shown to result in significant improvement in the detection rate of CHD of up to 70 %, as has been shown by Carvalho et al. [3] in a high-risk population and 74 % as recently shown by a study by Levy et al. [7] in a large low-risk population. The outflow tracts view has been shown to be more sensitive than the four-chamber view in detecting CHD in general as well as in detecting ductal-dependent forms of CHD [8]. This leaves no doubt that, in order to achieve a better prenatal detection rate of CHD in the general population, the addition of the outflow views to the routine fetal screening examination has to become mandatory. Given the importance of prenatal and early detection of congenital heart disease on postnatal outcome [2], these published practice guidelines will undoubtedly have a significant impact on the practice of fetal medicine. These guidelines represent an important effort to raise the bar and improve the rate of prenatal detection of CHD and as such advance the field of fetal cardiology. The inclusion of the assessment of both the 4-chamber and outflow tracts views in the screening process in large low-risk pregnancies, however, undoubtedly places a significant burden on practicing obstetricians and obstetric sonographers, many of whom were not trained to obtain K. A. Diab (&) S. Awad Pediatric Cardiology, Rush University Medical Center, 1653 W Congress Parkway, Chicago, IL 606012, USA e-mail: karim_diab@rush.edu

Clinical practice guidelines-Nursing management for pediatric patients with small bowel or multivisceral transplant

Small bowel or multivisceral transplant is a relatively new treatment for irreversible intestinal damage, and no published practice guidelines exist. The purpose of this article is to report evidence regarding the best plan of care to achieve adequate nutrition and appropriate development for children. An integrative review was conducted with 54 articles related to management of this transplant population. A nine-member nursing team integrated the findings. This resulting guideline represents the best research and best practices on which to base staff education and competency validations to manage this medically fragile patient population.

AAPM medical physics practice guideline 1.a: CT protocol management and review practice guideline.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.

Postanesthesia Evaluation of Neuromuscular Function

The American Society of Anesthesiologists’ recently published Practice Guidelines for Postanesthetic Care1 contains a statement that is at best puzzling and at worst I believe sends the wrong message to the anesthesia community. To quote: “Assessment of neuromuscular function primarily includes physical examination and, on occasion, may include neuromuscular blockade monitoring.”There is now overwhelming evidence that traditional bedside or clinical tests of neuromuscular function such as head-lift, tidal volume, tongue protrusion, and others are very insensitive tests for the detection of residual neuromuscular weakness.2–5 To cite just one recent study “a reliable clinical test for detection of significant residual block... will probably remain elusive.”6 Thus one must ask what clinical signs the Task Force is referring to when they recommend a “physical examination”?The answer to the problem of postoperative residual neuromuscular block lies not with a postanesthesia evaluation, but with intelligent intraoperative monitoring of neuromuscular function ideally with a quantitative monitor.

Research News: Patients With Obstructive Sleep Apnea and Ambulatory Surgery

In 2006, the American Society of Anesthesiologists (ASA) published practice guidelines for managing patients with OSA having surgery. Part of their report addressed whether patients with OSA were appropriate candidates for outpatient surgery. Specifically, experts (anesthesiologists, surgeons, and researchers) in the care of patients with OSA agreed that superficial surgery, minor orthopedic surgery using local or regional anesthesia, and lithotripsy may be performed safely on an outpatient basis. They agreed that the following should not be performed in an outpatient setting: airway surgery, tonsillectomy in children younger than 3 years, and laparoscopic and upper abdominal surgery. The opinions were divided on superficial and minor orthopedic surgery under general

Optimizing Fertility Preservation Practices for Adolescent and Young Adult Cancer Patients

Most adolescents and young adults (AYAs) with cancer will survive their disease, and fertility issues are a major concern for this population. The ASCO and new NCCN Clinical Practice Guidelines in Oncology for Adolescent and Young Adult Oncology recommend that oncologists offer the option of fertility preservation to all postpubertal AYAs before the start of potentially gonadotoxic chemotherapy or radiotherapy, providing that the patient does not require emergent start of therapy. Despite the published practice guidelines, many AYAs diagnosed with cancer are still not offered fertility preservation, with oncologists citing lack of time, lack of knowledge, and discomfort in discussing fertility and sexuality with AYAs as reasons. Developing a systematic and coordinated multidisciplinary strategy for fertility preservation referrals within a practice site may streamline the referral process, off-loading some tasks from the oncologist and potentially increasing patient satisfaction, provider satisfaction, and compliance with the guidelines.