Updated Guidelines For Management Research Articles

Updated Guidelines for Management of High Blood Pressure

Updated Guidelines for Management of High Blood Pressure

Interpatient variability in dexmedetomidine response: a survey of the literature.

Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients.

Endocrinologist-Performed Ultrasound-Guided Fine Needle Aspiration of Thyroid Nodules in Toronto

Radiologists traditionally perform ultrasound-guided fine needle aspiration (FNA) of thyroid nodules in Canada, with selection of nodules for FNA based primarily on nodule size. Most updated international guidelines for thyroid nodule management, however, recommend a consideration of medical history and sonographic features to delineate nodule/s for FNA. This is a retrospective analysis of FNAs performed by an endocrinologist in 3 centres of the Greater Toronto Area (Malton, Oakville and Thornhill). The study dataset includes 585 consecutive FNAs performed among 504 patients, with all specimens reported by a single cytopathologist. Cytology was reported as benign in 75%, malignant or suspicious in 5%, atypia in 3%, follicular neoplasm in 2% and nondiagnostic in 16% samples. Malignancy rate (suspicious/malignant cytology) was positively associated with male gender, age, radiation history and sonographic features (hypoechogenecity, irregular borders, microcalcifications and intranodular vascularity). Endocrinologist documented that high suspicion on FNA encounter was most predictive for malignancy. Nodule size (range 7 mm to 7.4 cm) was not associated with either malignancy or nondiagnostic rates. Eight percent sufficiency was observed on repeat FNAs among subjects with previous FNAs performed at other facilities (n=162), with 6% malignancy rate for previous nondiagnostic cytology reports; 20% malignancy rate for previous cytology reported as atypia. A combination of medical history and sonographic features documented by an endocrinologist yields a greater prediction of malignancy rates vs. the commonly used size criteria for selecting thyroid nodules for FNA in Canada. Overall, FNA sufficiency and malignancy rates in this Toronto-based study are consistent with published global literature.

Foreword

Foreword

Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update

BackgroundThe management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged.MethodsGeneral methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Evidence Based Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted.ConclusionsWe present the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.

Management options for metastatic melanoma in the era of novel therapies: A primer for the practicing dermatologist

The incidence of melanoma has increased for decades, and while surgical treatment of early stage disease is often curative, metastatic disease continues to carry a significantly less promising outlook with high associated health burden and economic cost. An expanding number of dermatologists are playing a key role in coordinating the care of patients with melanoma, including in an increasingly important role among multidisciplinary melanoma clinics, many of which are anchored in dermatology departments. Advances in the understanding of the genetic and immunoregulatory aspects of melanoma development and progression have yielded a wave of novel therapeutics that has made significant impact on the approach to patients with metastatic disease. Frequently updated management guidelines and unfamiliarity with approved adjuvant treatment options, including interferon, clinical trials, or radiation therapy, can pose a challenge for dermatologists seeking to effectively coordinate the care of and establish proper expectations for patients with stage III disease. Moreover, greater awareness of treatment modalities for in-transit disease may allow dermatologists to play a more active role in the treatment of these patients and to expand their ability to explain and coordinate options, such as limb perfusion or infusion. Part I of this continuing medical education article will use clinical scenarios to outline the current management options for patients with stage III melanoma, including both adjuvant treatment options for resected stage III disease and primary treatment options for in-transit metastases. Part II of this series will address stage IV disease.

Updated Pain Guidelines

Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dkRecently, the American Society of Anesthesiologists Task Force on Acute Pain Management published an “updated report and practice guidelines for acute pain management in the perioperative setting.”1Although this is a laudable effort and the Task Force committee includes anesthesiologists with established expertise in the topic, I must admit as a surgeon with an interest in analgesia and postoperative recovery that I have several concerns on the overall message of the practice guidelines. First, it is claimed that the present guidelines differ from existing guidelines by providing “new evidence in an updated evaluation of scientific literature,” but a closer look at the reference material including almost 250 references shows less than 10 references from 2009 and upward. Many publications on single analgesic interventions as well as multimodal techniques have been published in the last 3 yr, which may change their conclusions if updated. For instance, by several meta-analyses or reviews on interventions like preventive analgesia, paravertebral blocks in pulmonary surgery, epidural analgesia in laparoscopic colonic surgery, local infiltration analgesia versus spinal analgesia in hernia surgery, and high-volume infiltration analgesia in major lower-limb arthroplasty versus peripheral blockades as well as the many efforts to provide improved analgesia and/or opioid-sparing by a combination of nonopioid analgesics. Importantly, many publications from the PROSPECT Collaboration Group have provided procedure-specific recommendations for perioperative acute pain management—which was not discussed in the present guidelines. This may be clinically important, because it has become evident that choice of analgesia is highly dependent on the specific surgical procedure regarding analgesic efficacy, potential side effects, and effects on recovery.Neither was there a comment on the extensive Australian and New Zealand guidelines for perioperative pain management.*†In summary, updated practice guidelines for acute pain management therefore must be based upon the available procedure-specific, multimodal opioid-sparing techniques and within a context to provide a rational basis for enhanced postoperative recovery and reduction of morbidity.2Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dk

Three Reasons to Abandon Low-Density Lipoprotein Targets

The updated clinical guidelines for cholesterol testing and management (Adult Treatment Panel (ATP) IV) from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are under development and due to be published in 2012. These influential guidelines are organized and funded by the National Heart, Lung, and Blood Institute (NHLBI) and carry the imprimatur of the federal government. In this iteration, the NHLBI has a stated goal of integrating its set of Cardiovascular Risk Reduction guidelines.1 A primary focus of the previous version of the guidelines, ATP III, was a strategy of treating patients to target low-density lipoprotein (LDL) cholesterol levels. ATP III stated that “recent clinical trials robustly show that LDL-lowering therapy reduces risk for CHD. For these reasons, ATP III continues to identify elevated LDL cholesterol as the primary target of cholesterol-lowering therapy. As a result, the primary goals of therapy and the cutpoints for initiating treatment are stated in terms of LDL.” This reasoning, however, diverged from the clinical evidence, recommending an approach that was not tested in any clinical trial. Outcomes research promotes the need to demonstrate benefit before making recommendations for medical intervention.2,3 In that spirit, we present an open letter to the ATP IV Committee that provides the rationale for why the new guidelines should abandon the treat-to-target paradigm. Dear ATP IV Committee, We are writing to encourage you to abandon the paradigm of treating patients to LDL targets, a change that will better align ATP IV with current clinical evidence. Changing long-held beliefs is never easy, even when the need for change is based on strong evidence. Change is especially difficult when prior beliefs are firmly embedded in culture, accepted as dogma, and codified in books, articles, guidelines, public service announcements, and performance measures. …

Management of radiation dermatitis in patients receiving cetuximab and radiotherapy for locally advanced squamous cell carcinoma of the head and neck: proposals for a revised grading system and consensus management guidelines

BackgroundRadiation dermatitis developing in patients receiving cetuximab concomitantly with radiotherapy for locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) is now recognized to have different pathophysiological and clinical characteristics to the radiation dermatitis associated with radiotherapy or concomitant chemotherapy and radiotherapy. Current grading tools were not designed to grade this type of radiation dermatitis; their use may lead to misclassification of reactions and inappropriate management strategies, potentially compromising cancer treatment. Patients and methodsAn advisory board of seven leading European specialists (three medical oncologists, three radiation oncologists and a dermatologist) with extensive experience of the use of cetuximab plus radiotherapy produced consensus guidelines for the grading and management of radiation dermatitis in patients receiving cetuximab plus radiotherapy. ResultsModifications to the current, commonly used National Cancer Institute—Common Terminology Criteria for Adverse Events version 4.3 for grading radiation dermatitis were proposed. Updated management guidelines, building on previously published guidelines from 2008, were also proposed. ConclusionsThe proposed revisions to the grading system and updated management guidelines described here represent important developments toward the more appropriate grading and effective management of radiation dermatitis in patients receiving cetuximab plus radiotherapy for LA SCCHN.

Updated guideline for COPD management

Updated guideline for COPD management

Combined management of open tibial fractures course

Lower limb trauma can present complex problems, and early correct management is crucial to optimise outcome. This can be difficult, however, especially in non-specialist centres where people with these injuries sometimes present. In an attempt to improve the delivery of surgical care, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have recently published updated management guidelines, the Standards for the Management of Open Fractures of the Lower Limb (2009; www.bapras.org.uk/downloaddoc.asp?id=141). The aims of these guidelines, and of the course, are to encourage cooperation between plastic surgeons and orthopaedic surgeons and to provide an evidence based rationale for treatment. This course complements the recent updated guidelines, and four of its authors teach the course. They are recognised for their expertise in the field and come from a background of orthopaedics, plastic surgery, and infectious diseases. The course …

Perspectives on the 2009 Focused Updates on the Management of ST-Segment Elevation Myocardial Infarction and Percutaneous Intervention

The American College of Cardiology, American Heart Association and Society of Angiography and Intervention recently published updated guidelines for management of patients with acute ST elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI). In this article, we highlight the most important new recommendations and review the supporting data. Key aspects of these updates include guidance regarding the selection of antithrombotic therapy, caution in treating hyperglycemia with insulin, and opinion that insufficient data currently exist to recommend against concomitant administration of proton pump inhibitors and thienopyridines. New interventional recommendations include support for aspiration thrombectomy, drug eluting stents, PCI of unprotected left main disease, and use of fractional flow reserve to guide whether PCI is warranted in symptomatic patients with intermediate coronary stenoses. As these guidelines represent a synopsis of the most recently available data in the management of patients with STEMI, health care providers should familiarize themselves with these updated recommendations to ensure optimal treatment of their patients.

Hereditary diffuse gastric cancer: updated consensus guidelines for clinical management and directions for future research

25–30% of families fulfilling the criteria for hereditary diffuse gastric cancer have germline mutations of the CDH1 (E-cadherin) gene. In light of new data and advancement of technologies, a multidisciplinary...

WITHDRAWN: On the updated ECCO consensus guidelines for medical management of Crohn's disease

WITHDRAWN: On the updated ECCO consensus guidelines for medical management of Crohn's disease

The Updated American Thyroid Association Guidelines for Management of Thyroid Nodules and Differentiated Thyroid Cancer: A Surgical Perspective

The new ATA Guidelines are a welcome ‘‘upgrading’’ of the initial work published in 2006, made necessary by the ever-changing evidence from new studies with compelling data and high quality methodology. The role of clinical research is to allow us to rationalize and refine our practices for the benefit of our patients: ‘‘Use of the best information, thus minimizing bias and opinion, is the key element that separates ethical medical practitioners from quacks and charlatans’’ (1). This was the role of the task force in reviewing this new information, evaluating its scientific quality and its clinical implications, and ‘‘digesting’’ it into clear, precise, state-ofthe-art guidelines. New evidence concerning the surgical management of thyroid carcinoma has allowed the task force to refine their recommendations in this latest version of the Guidelines. Concerning total thyroidectomy versus lobectomy, the new Guidelines have refined the indications with more precise wording, in part based on data from a recent study of more than 50,000 patients that showed significantly improved recurrence and survival rates after thyroidectomy as opposed to lobectomy for tumors larger than 1 cm (2). This new highquality evidence has changed Recommendation 26 from ‘‘for most patients with thyroid cancer’’ to ‘‘for patients with thyroid cancer larger than 1 cm, the initial procedure should be a near-total or total thyroidectomy.’’ This is clear and evidence based and closes the debate between total thyroidectomy and lobectomy for thyroid carcinoma. Another major modification in the new Guidelines concerns the central compartment (level VI) neck dissection for papillary thyroid carcinoma. The current guidelines are more explicit in the distinction between prophylactic neck dissection (for patients clinically and radiologically N0) and therapeutic neck dissection (for patients cN1) and their respective indications. Recommendation 27a and 28 together state that central and lateral neck dissection should be performed for patients with clinically involved central or lateral neck nodes. This clear recommendation is based on accumulated evidence that therapeutic neck dissection may improve loco-regional control, decrease the need for repeated treatment with radioiodine, and may improve survival. Prophylactic neck dissection poses a problem. The risk to benefit ratio is difficult to evaluate given current evidence and conflicting data. There is no level I evidence that prophylactic central compartment neck dissection improves loco-regional control or disease-specific survival (3). Prophylactic central compartment neck dissection was shown in one study to increase the proportion of disease-free patients as documented by unmeasurable thyroglobulin levels postoperatively (4), but other similar studies have failed to show this advantage. There seem to be, nonetheless, advantages to performing a prophylactic central compartment neck dissection, and the new Guidelines have included a lengthier discussion with more data concerning its risks and benefits. The new Guidelines clearly state that intraoperative inspection of the central compartment is not a sensitive procedure for detecting metastatic nodes, a notion that is not new (5) and that exists for other head and neck cancers as well, but that seems to not have had any practical consequences for a number of surgeons. The limits of ultrasound detection in the central compartment are also clearly stated and are related to the small size of metastatic nodes; the difficult access to the region due to its small size, adjacent bones, and trachea; and the operatordependent nature of ultrasound itself. Lymph node staging using sentinel node biopsy has not been validated for thyroid cancer. It is apparent that currently the best procedure for obtaining a precise nodal staging is prophylactic lymph node dissection. The advantage of precise staging for low-risk patients has been shown in a recent study of patients with tumors less than 2 cm: the decision for adjuvant treatment with radioiodine was modified by the presence or absence of lymph node metastases for 30% of the 82 patients with pT1 tumors (6). Prophylactic central neck dissection may reveal more aggressive tumors than suspected, upstaging some patients (about 15% of the T1 tumors in the above study) and providing evidence in favor of radioiodine therapy for these selected cases. On the other hand, radioiodine was avoided for another 15% of the cases in the above study, due to negative pathology on analysis of the central compartment neck dissection. Avoiding radioiodine in low-risk patients avoids excess risk such as alterations in salivary and gonadal function or radio-induced cancers. According to the new Guidelines, radioiodine may or may not be indicated for patients with T1 or T2 tumors (Table 5 and

Management guidelines for the use of alemtuzumab in chronic lymphocytic leukemia

The consensus views of an expert roundtable meeting are presented as updated management guidelines for using alemtuzumab in chronic lymphocytic leukemia. Since the publication of previous management guidelines in 2004, clinical experience with alemtuzumab has grown significantly, especially regarding its efficacy and safety, management of cytomegalovirus (CMV) reactivation, identification of patient subgroups likely to benefit from alemtuzumab therapy and subcutaneous administration of alemtuzumab. The updated recommendations include (1) alemtuzumab monotherapy can be safely used as first-line therapy; (2) suitable patient subgroups for alemtuzumab therapy include elderly patients, patients with 17p deletion, patients with refractory autoimmune cytopenias and patients with profound pancytopenia at baseline due to heavily infiltrated bone marrow; (3) alemtuzumab treatment should be continued for 12 weeks (36 doses) whenever possible, and bone marrow examination may be considered at week 12 to evaluate response; (4) monitoring CMV reactivation by weekly PCR is mandated during therapy; when CMV reactivation becomes symptomatic or viremia increases, alemtuzumab therapy should be interrupted and anti-CMV therapy started; (5) subcutaneous administration is safe, easy to perform and appears equally effective compared with intravenous infusion and (6) our strong recommendation is that alemtuzumab combination therapy and consolidation therapy shall not be used outside carefully controlled clinical studies.

Cervical Cytology Specimen Adequacy

To provide updated management guidelines according to cervical cytology specimen adequacy and techniques to optimize adequacy based on literature review and expert opinion. Selected members of the American Society for Colposcopy and Cervical Pathology committee and invited experts conducted a literature review and discussed appropriate management and areas for future research emphasis. The guidelines recommend a repeat Pap test in a short interval of 2 to 4 months for most women when the cytology result is unsatisfactory. The preferred follow-up for women with a negative cytology result lacking an endocervical/transformation zone component or showing other quality indicators is a repeat Pap test in 12 months. Indications for an early repeat Pap test in 6 months are provided, and the influence of human papillomavirus testing results on management is discussed. Techniques for optimizing specimen adequacy are provided in detail. The specimen adequacy management guidelines will help promote uniform and optimal follow-up of patients receiving cervical cytology screening. The topics for future research emphasis will be helpful in promoting studies in needed areas.

Development of a Soil Conservation Standard and Guidelines for OHV Recreation Management in California

In 2004, the California State Parks (CSP) agency contracted with the California Geological Survey (CGS) to update the 1991 Soil Conservation Guidelines/Standards for Off-Highway Vehicle (OHV) Recreation Management. Per state legislation, the 1991 standards were updated to establish a generic and measurable standard at least sufficient to allow restoration of OHV areas and trails. Given the rapid increase in OHV use in California, the updated Soil Conservation Standard and Guidelines for OHV Recreation Management also allowed for sustainability of trail systems and recreation opportunities. A key part of the update was interaction with stakeholders, agencies, and other interest groups through public workshops and a Consulting Agency Review Committee composed of representatives from the U.S. Natural Resources Conservation Service, U.S. Forest Service, U.S. Bureau of Land Management, U.S. Geological Survey, California Department of Conservation, and CSP. CGS also assessed proposed revisions in three representative OHV areas to ensure that the updated Standard and Guidelines provided sufficient flexibility to allow their application to all sites state-wide, ecosystems with multiple geology and soils types, and a variety of vehicle uses. While geology was not the only basis for the guideline revisions, it was a major factor. CGS staff also had the breadth of knowledge and experience in engineering geology, hydrogeology, road and trail construction, erosion control, and OHV riding necessary to coordinate and develop the multi-disciplinary and multi-stakeholder effort.

Promulgation of guidelines for mucositis management: educating health care professionals and patients

The Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) Mucositis and Patient and Professional Education Study Groups are collaborating to improve the promulgation of the updated mucositis management guidelines. The initial step in the collaboration was to survey cancer care health professionals to determine their awareness of the original 2004 guidelines and their opinions on the usefulness of patient educational materials based on the guidelines. The authors surveyed four samples (three US and one European) of cancer health care professionals attending three cancer-related professional conferences between May and July 2005 using a ten-item questionnaire in both paper-and-pencil and web-based formats. Data were compiled and analyzed using descriptive statistics. All respondents were generally aware of the importance of mucositis as a treatment-limiting toxicity with life-threatening complications and endorsed regular oral assessment and dental care practices. Only about one third of the US respondents were aware of the 2004 guidelines in contrast to 80% of the European respondents. A majority of respondents across all four surveys (66-93%) felt strongly that educational materials based on the guidelines were needed and that they would use them, while a smaller number (7-29%) indicated they might use them if a patient had a problem with mucositis. Awareness of the guidelines remains limited in the US, and use of the guidelines worldwide is minimal. The Mucositis and Patient and Professional Education Study Groups have developed a set of strategies to enhance dissemination, awareness, and use of the updated guidelines and to promote patient education based on the guidelines. Future work will focus on implementation and evaluation of the guidelines in clinical practice.

Omalizumab: A Steroid-sparing Option for Improving Pediatric Asthma Management?

About 9 million children less than 18 years of age have been diagnosed with asthma at some point in their lifetime (Centers for Disease Control [CDC], 2005). Not only is the number of asthma cases increasing, but there is also a continued increase in morbidity due to asthma. Asthma remains a challenge in childhood even with improving therapies and updated management guidelines. Leukotriene modifiers, mast cell stabilizers and inhaled corticosteroids are the anti-inflammatory agents available for children.