Standards For Clinical Guidelines Research Articles

Return of intracranial beta oscillations and traveling waves with recovery from traumatic brain injury.

Traumatic brain injury (TBI) remains a pervasive clinical problem associated with significant morbidity and mortality. However, TBI remains clinically and biophysically ill-defined, and prognosis remains difficult even with the standardization of clinical guidelines and advent of multimodality monitoring. Here we leverage a unique data set from TBI patients implanted with either intracranial strip electrodes during craniotomy or quad-lumen intracranial bolts with depth electrodes as part of routine clinical practice. By extracting spectral profiles of this data, we found that the presence of narrow-band oscillatory activity in the beta band (12-30 Hz) closely corresponds with the neurological exam as quantified with the standard Glasgow Coma Scale (GCS). Further, beta oscillations were distributed over the cortical surface as traveling waves, and the evolution of these waves corresponded to recovery from coma, consistent with the putative role of waves in perception and cognitive activity. We consequently propose that beta oscillations and traveling waves are potential biomarkers of recovery from TBI. In a broader sense, our findings suggest that emergence from coma results from recovery of thalamo-cortical interactions that coordinate cortical beta rhythms.

Management of asthma exacerbations in the paediatric population: a systematic review.

Asthma exacerbations in children is one of the most common medical conditions requiring urgent visits to primary healthcare providers or emergency departments, and even hospitalisations. Currently, there is significant variation in the management of asthma exacerbations expressed in guideline recommendations versus clinical practice. This disconnect affects diagnostic and treatment decisions for the clinician and patient. We systematically reviewed the available guidelines providing recommendations for diagnostic and therapeutic management of asthma exacerbations in the paediatric population. A systematic review of the literature for guidelines published between January 2009 and October 2019 was conducted, using a protocol registered with the international prospective register of systematic reviews (PROSPERO CRD42020221562). 16 asthma exacerbation clinical practice guidelines for children were included. Despite general agreement between guidelines on the definition of asthma exacerbation, there was great variability in the definition of disease severity and assessment of asthma control. This systematic review also highlighted a paucity of recommendations for criteria for hospitalisation and discharge. Many guidelines scored poorly when measured for stakeholder involvement and editorial independence. Comprehensive and updated guidelines compliant with international standards for clinical guidelines may significantly improve clinical practice quality, promote evidence-based recommendations and provide uniformity of treatment between countries.

A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis.

Bronchiolitis is the leading cause of hospital admission for respiratory disease among infants aged <1 year. Clinical practice guidelines can benefit patients by reducing the performance of unnecessary tests, hospital admissions, and treatment with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality, and discuss variability across guidelines for the diagnosis and management of bronchiolitis. A systematic literature review of electronic databases EMBASE, Global Health, and Medline was performed. Manual searches of the gray literature, national pediatric society websites, and guideline-focused databases were performed, and select international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research and Evaluation assessment tool was used by 2 independent reviewers to appraise each guideline. Thirty-two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines, including lack of systematic processes in formulating guidelines, failure to state conflicts of interest, and lack of consultation with families of affected children. There was widespread agreement about a number of aspects, such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria, and nosocomial infection control. However, there was variability, even within areas of consensus, over specific recommendations, such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations over whether use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely trialled. Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality and clarity and to promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management, and platforms should be created to understand this variability and promote evidence-based recommendations.

Staff and clinic protection during COVID pandemic

The impact of novel coronavirus pandemic (COVID-19) on the healthcare system has been devastating and the medical fraternity is facing challenges to tackle this catastrophic outbreak. With regard to dermatology practice, we review various outbreak response measures to be followed by the dermatology staff at clinic in constrained environment. Preventive measures like social distancing, hand hygiene practices and protective measures such as introduction of personal protective equipment (PPE) for staff, standardization of clinical guidelines and continuing medical services via teleconsultation are recommended. Physical consultation has been limited to emergency-based services. Although teledermatology would never replace physical consultation, it might serve as an adjunctive role in providing adequate services to the non-emergent conditions and minimizes the risk of exposure of both doctors and patients. Non-urgent visits of the patients are being discouraged and elective dermatology procedures are being postponed. Dermatologists should also recognize and educate health care workers about primary cutaneous features of COVID-19 as well possible dermatological side effects arising from prolonged usage of PPE and hand hygiene practices. Limited office-based and in-patient services with a parallel increase in teledermatology consultations will allow effective dermatologic care and services to the public while ensuring minimum transmission of the virus.

Antibiotic Prescribing in Ambulatory Care of Pediatric Patients with Respiratory Infections

Respiratory tract infections represent the most frequent conditions in pediatric clinical practice that motivate antibiotic prescribing. The objective was to identify the frequency and pattern of antibacterial prescribing in respiratory diseases. Over a period of two years (divided by the presentation of the clinical guideline standards) data was collected from clinical records of children with respiratory disease. Chi-square tests or Fisher's exact test were used to test associations between variables, statistical significance p < 0.05. There were 547 visits (mean age 6 years ± 5.3, 55% male gender). Analysis for Group A Streptococcus of the oropharynx was most frequently requested by pediatric residents (p = 0.005). Chest x-rays were more frequently requested by the Family Physician (p = 0.033). An antibiotic was prescribed in 87% of pneumonias, 84% acute otitis media, 68% acute tonsillitis, 25% laryngitis, 17% upper respiratory infections, 16% acute bronchiolitis. The Family Physician prescribed antibiotics more often than the Pediatrics resident in acute tonsillitis (p = 0.003) and in acute otitis media (p = 0.013). The most frequently prescribed antibiotic was amoxicillin (61%). There were no significant differences between the two periods studied regarding the number of prescriptions and antibiotic choice of the conditions studied. Antibiotic prescribing in pediatric acute respiratory infections was high and the choice of antibiotic therapy could be adjusted. We found no difference in antibiotic prescribing after the presentation of the clinical guideline standards. An improvement in the antibiotic prescription in children and adolescents in the outpatient clinic is considered necessary.

The different clinical guideline standards in Brazil: High cost treatment diseases versus poverty-related diseases.

Each year, evidence-based clinical guidelines gain more space in the health professionals’ practice and in services organization. Due to the scarcity of scientific publications focused on diseases of poverty, the development of well-founded clinical guidelines becomes more and more important. In view of that, this paper aims to evaluate the quality of Brazilian guidelines for those diseases. The AGREE II method was used to evaluate 16 guidelines for poverty-related diseases (PRD) and 16 guidelines for global diseases whose treatment require high-cost technologies (HCD), with the ultimate aim of comparing the results. It was found that, in general, the guideline development quality standard is higher for the HCD guidelines than for the PRD guidelines, with emphasis on the "rigour of development" (48% and 7%) and "editorial independence" (43% and 1%) domains, respectively, which had the greatest discrepancies. The HCD guidelines showed results close to or above international averages, whereas the PRD guidelines showed lower results in the 6 domains evaluated. It can be concluded that clinical protocol development priorities need some redirecting in order to qualify the guidelines that define the healthcare organization and the care of vulnerable populations.

The Challenge of Guideline Development When Evidence Is Sparse.

Although best-practice standards for clinical guidelines have been released by the Institute of Medicine and Guidelines International Network, a great challenge remains for guideline development for patients afflicted with rare diseases. This article reviews the challenge of guideline development under these circumstances with an emphasis on strategies to overcome these challenges. Guideline development and use in practice have become integral components in the contemporary care of patients to optimize outcome results. The guidelines are developed through an objective, evidence-based process conducted by experts and stakeholders for a given disease process.

Amended Classification of the Open Abdomen.

In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research. As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen. The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue. The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.

Perioperative pain therapy in orthopedics

A sufficient pain management forms the foundation for a successful operative treatment of orthopedic patients. Clinical guideline standards must be provided to ensure safe and immediate pain therapy. Training in these guidelines should be held for clinical personnel on a regular basis. The visual analog scale (VAS) and the numerical rating scale (NRS) are valid instruments used for assessment of pain intensity. A sufficient pain management includes basic analgesics, analgesics on demand as well as special features, such as regional nerve blocks and patient-controlled anesthesia (PCA). The basic analgesics are primarily the groups of classical non-steroidal anti-inflammatory drugs (NSAID) and cyclooxygenase 2 (COX-2) inhibitors as well as stand by analgesics, such as metamizole. If there is further need for pain therapy, medium strong and strong opioids can be used but adverse events must be taken into consideration.

Patient-centered guideline development: best practices can improve the quality and impact of guidelines.

Guideline development is improved when diverse stakeholders, including patients, specialists, and experts, share power in the process, from defining the scope of the question to the final stages of review. The Institute of Medicine (IOM) and Guidelines International Network (G-I-N) have each released best-practice standards for clinical guidelines that place health care consumers at the forefront of guideline development. The AAO-HNSF has placed a growing emphasis on consumer engagement in its latest guideline development manual and has developed clear, multifaceted infrastructural approaches to identify and utilize consumers in guideline development and guideline review. This article reviews those recommendations and emphasizes that patient-centered guideline development can improve the quality and impact of medical guidelines.

Inequalities in Stroke Patients' Management in English Public Hospitals: A Survey on 200,000 Patients

BackgroundAccording to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) - Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the studyTo describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.MethodsWe collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.ResultsIn English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P<0.001), male (P = 0.012), and least socio-economically deprived patients (P = 0.001), as well as patients with fewer comorbidities (P<0.001) appear to have more chance of being selected for a brain scan.ConclusionSome English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities.