NHS Greater Glasgow and Clyde
- Clinical Librarian -
NHSGGC Partnerships Guidelines Newsletter
September 2006
Welcome to the Partnerships Guidelines Newsletter. The newsletter is intended as an information tool to help you
keep up to date with developments in your area of clinical expertise and interest. It is not in any way an
expression of organisational policy. The inclusion of a guideline in this newsletter does not imply that it is used, or
should be implemented, within NHS Greater Glasgow and Clyde. Any views expressed in guidelines quoted in
the newsletter will have to be subjected to the scrutiny of your own clinical judgement. You are, however,
welcome to use the guideline newsletter to inform your practice or service development.
This newsletter covers national and international guidelines that have either been published or added to specialist
databases (such as Medline or CINAHL) in the previous month. It is divided into three sections: one for clinical
guidelines from the UK, one for clinical guidelines from international bodies and one for publications on guideline
implementation. Within the two clinical sections, there are sub-categories to make it easier for you to find the
guidelines that might be relevant to your practice.
Where available, the newsletter includes abstracts and links to online full-text versions or executive summaries of
the guidelines.
Contents
A. UK Guidelines …………………………………………………………………………………………………….
p.2
Primary Care
………………………………………………………………………………………….
Cancer Care/Palliative Care
……………………………………………………………………………….
Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
………………………………………………………………………………………….
p. 2
p. 2
p. 2
p. 2
p. 2
p. 3
B. International Guidelines ………………………………………………………………………………………….
p. 4
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
Primary Care
………………………………………………………………………………………….
Cancer Care/Palliative Care
…………………………………………………………………….
Mental Health and Learning Disabilities …………………………………………………………………….
Dentistry
………………………………………………………………………………………….
Sexual Health, BBV and related Topics …………………………………………………………………….
Child Health
………………………………………………………………………………………….
C. Guidelines Implementation ……………………………………………………………………………………….
p. 4
p. 12
p. 14
p. 17
p. 17
p. 19
p. 20
If you would like to obtain full text versions of any of the guidelines listed in the newsletter, please refer to the
NHSScotland e-Library where you will find most of the guidelines in full text. The e-Library is accessible to all
NHSScotland staff at http://www.elib.scot.nhs.uk. Full text access requires an ATHENS password, which can be
obtained online from the e-Library website. For those guidelines that are not available online, please fill in and
sign the document request form that is included with the newsletter and send it to the Maria Henderson Library,
Gartnavel Royal Hospital. Phone: 0141-211 3913.
1
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
A. UK Guidelines
Primary Care
No relevant new guidance was published this month.
Back to the Contents page
Cancer Care/Palliative Care
No relevant new guidance was published this month.
Back to the Contents page
Mental Health and Learning Disabilities
No relevant new guidance was published this month.
Back to the Contents page
Dentistry
No relevant new guidance was published this month.
Back to the Contents page
Sexual Health, BBV and related Topics
Faculty of Family Planning and Reproductive Health Care (FFPRHC). Service Standards for
Medicines
Management.
London:
RCOG,
2006.
URL:
http://www.ffprhc.org.uk/admin/uploads/582_ServiceStandardsMedicinesManagementMay06.pdf [last
accessed: 13 September 2006].
Faculty of Family Planning and Reproductive Health Care (FFPRHC). Service Standards for
Resuscitation
in
Sexual
Health
Services.
London:
RCOG,
2006.
URL:
http://www.ffprhc.org.uk/admin/uploads/962_ServiceStandardsResuscitationSHServices.pdf
[last
accessed: 13 September 2006].
Faculty of Family Planning and Reproductive Health Care (FFPRHC). First Prescription of
2
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
Combined
Oral
Contraception.
London:
RCOG,
2006.
http://www.ffprhc.org.uk/admin/uploads/FirstPrescriptionCombinedOralContraceptionCEU.pdf
accessed: 13 September 2006].
URL:
[last
Back to the Contents page
Child Health
No relevant new guidance was published this month.
Back to the Contents page
3
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
B. International Guidelines
Primary Care
A. P. I. Consensus Expert Committee. API TB Consensus Guidelines 2006: Management of
pulmonary tuberculosis, extra-pulmonary tuberculosis and tuberculosis in special situations.
Journal of the Association of Physicians of India 54 2006: 219-34.
INTRODUCTION: The World Health Organization (WHO) has declared Tuberculosis (TB) a global
emergency in 1993. Prevalence of TB and Human Immunodeficiency Virus (HIV) co-infection worldwide
is 0.18% and about 8% TB cases have HIV infection. Effective chemotherapy has been available for
treatment of TB for over 50 years now. In World Health Organization (WHO)-International Union Against
Tuberculosis and Lung Disease (IUATLD) Working Group Global Anti-Tuberculosis Drug Resistance
Surveillance (1994-1997), the incidence of MDR TB in Delhi was found to be 14%, of which primary
multi-drug resistance was only 1.4%, indicating that most of MDR TB is acquired as a result of poor
chemotherapy. DIAGNOSIS OF TB: Since TB is an infectious disease caused by Mycobacterium (M)
tuberculosis the diagnosis of TB should (as far as possible) be by demonstration of M. tuberculosis on
culture or acid-fast bacilli (AFB) on smear examination. The World Health Organization (WHO) has
strongly recommended sputum smear examination as the preferred screening test and suggests
examination of 3 deeply coughed out sputum samples - spot sample on day 1, overnight sample and a
spot sample in the morning on day 2. Recently it has been shown that sputum smear positivity is greater
than 90% where greater than 5 ml of sputum is used for smear diagnosis of pulmonary TB. Culture of M.
tuberculosis is the gold standard for diagnosis of TB. Culture of mycobacteria is a much more sensitive
test than smear examination and has been estimated to detect 10-100 viable mycobacteria per ml of
sample and in case of active disease they are found to be 81% sensitive and 98.5% specific. Culture
methods are also required for further drug sensitivity testing in cases of suspected drug resistant cases.
Isoniazid and rifampicin resistance can be reliably measured; resistance to pyrazinamide, ethambutol,
and streptomycin is more difficult due to limitations of technique. The therapeutic index for a given drug
is low for certain second-line drugs such as ethionamide, cycloserine, viomycin and para amino salicylic
acid (PAS) and it leads to misinterpretation of results due to failure to distinguish between sensitive and
resistant strains. Misdiagnosis of MDR-TB due to laboratory related errors has been reported recently.
MANAGEMENT OF TB: Chemotherapy of TB consists of prevention of infection, also called primary
chemoprophylaxis, when isoniazid 5 mg/kg is given to prevent infection in newborn infants of infectious
mothers till mother is sputum smear positive (2-3months). Treatment of latent tuberculosis, also called
secondary chemoprophylaxis, when isoniazid 5 mg/kg is given for 6 months to prevent disease in
infected persons (asymptomatic MT positive individuals) and treatment of disease with Short Course
Chemotherapy (SCC), as per WHO categories. Essential anti-tuberculosis (ATT) drugs Isoniazid (H),
Rifampicin (R), Ethambutol (E), Pyrazinamide (Z) and Streptomycin (S) are the essential first line antituberculosis drugs. Anti TB regimen consists of two phases: an initial intensive phase (IIP) and a
continuation phase (CP). Best effective SCC for treatment of TB, for adults and children, for pregnant
and lactating females, for cases associated with diabetes mellitus and HIV infection, for cases with preexisting liver diseases (but normal liver functions) and mild renal failure is 2EHRZ, 4HR given daily or
thrice weekly. Higher dose SCC intermittent therapy given in thrice weekly (2E3H3R3Z3, 4H3R3) has
now been advocated by WHO and implemented by the Revised National TB Control Programme. DOTS,
directly observed therapy short course, where the patient takes the drugs under the direct observation
(DO) of a health worker to ensure regularity of consumption of drugs. Fixed dose combinations (FDCs)
drugs consisting of two or three antituberculosis medications, provide a realistic and welcome alternative
to DO that minimizes the opportunity for a patient to selectively take only a single medication.
MANAGEMENT OF TB IN SPECIAL SITUATIONS: Pregnancy: All drugs, that is, rifampicin, isoniazid,
ethambutol, and pyrazinamide can be used during pregnancy. Streptomycin is not given due to
ototoxicity to the fetus. Prophylactic pyridoxine in the dose of 10mg/day is recommended along with ATT.
Diabetes mellitus: The drug regimen is same as in nondiabetic. Strict control of blood glucose is
mandatory. Also, doses of oral hypoglycemic agents may have to be increased due to interaction with
Rifampicin. Prophylactic pyridoxine is indicated. Renal failure: Dosages may have to be adjusted
according to the creatinine clearance especially for streptomycin, ethambutol and isoniazid. In acute
renal failure, ethambutol should be given 8 hours before hemodialysis. In post renal transplant patients:
Rifampicin-containing regimens are avoided as rifampicin causes increased clearance of cyclosporin.
Pre-existing liver disease: In stable disease with normal liver enzymes, all anti-tuberculous drugs may be
used but frequent monitoring of liver function tests is required. Treatment in unconscious patient
(patients unable to swallow): If patients are fed by Ryle's tube or gastrostomy tube, usual doses and
drugs may be powdered and administered avoiding feeds 2-3 hours before and after the dose. In cases
4
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
where enterostomy has been performed or parenteral nutrition is being used, intramuscular streptomycin
and isoniazid and intravenous quinolones may be used and switch to oral therapy once oral feed
resume. Treatment of TB with HIV co-infection: In early stages the presentations of TB in TB-HIV coinfection is the same as HIV negative but in late stages extra-pulmonary and dissemination are common.
The usual short course chemotherapy is indicated in HIV positive patients. The response is usually good
but relapse is frequent. After initiating ATT or anti-retroviral therapy (ART) worsening of preexisting
lesions or appearance of new lesions is seen, "paradoxical response" or "immune reconstitution
phenomenon". Multidrug resistant TB can occur due to poor compliance to ATT due to behavioural
pattern, increased incidence of side effects and malabsorption of drugs due to associated diarrhea. ART
for HIV, containing protease inhibitors (PI) and non-nucleoside reverse transcriptase inhibitors (NNRTI)
cannot be used along with R, as R induces metabolism of PI and reduces the efficacy. The various
options are i) to postpone anti-retroviral therapy ii) to use no PI or NNRTI containing anti-retroviral
combinations iii) to use certain PI/ and/or NNRTIs with modification in doses iv) Efavirenz (EFZ) or
Saquinavir with Ritonavir, without the need to adjust the doses v) to use non R regimens e.g.
2SHEZ+10HE MANAGEMENT OF MDR TB: As far as possible treatment of MDR TB should be referred
to specialized units with facilities for quality controlled DST and experienced in handling such cases. If
such referrals are not possible, one must remember that while initiating or revising therapy for MDR-TB,
drugs selection must rely on prior treatment history, results of susceptibility testing and an evaluation of
the patient's adherence.
Advisory Committee on Immunization Practices, Smith NM, Bresee JS, Shay DK, Uyeki TM, Cox NJ,
et al. Prevention and Control of Influenza: recommendations of the Advisory Committee on
Immunization Practices (ACIP). Morbidity & Mortality Weekly Report. Recommendations & Reports
55(RR-10) 2006: 1-42.
This report updates the 2005 recommendations by the Advisory Committee on Immunization Practices
(ACIP) regarding the use of influenza vaccine and antiviral agents (CDC. Prevention and control of
influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR
2005;54[No. RR-8]:1--44). The 2006 recommendations include new and updated information. Principal
changes include 1) recommending vaccination of children aged 24-59 months and their household
contacts and out-of-home caregivers against influenza; 2) highlighting the importance of administering 2
doses of influenza vaccine for children aged 6 months--<9 years who were previously unvaccinated; 3)
advising health-care providers, those planning organized campaigns, and state and local public health
agencies to a) develop plans for expanding outreach and infrastructure to vaccinate more persons than
the previous year and b) develop contingency plans for the timing and prioritization of administering
influenza vaccine, if the supply of vaccine is delayed and/or reduced; 4) reminding providers that they
should routinely offer influenza vaccine to patients throughout the influenza season; 5) recommending
that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in
the United States until evidence of susceptibility to these antiviral medications has been re-established
among circulating influenza A viruses; and 6) using the 2006-07 trivalent influenza vaccine virus strains:
A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, manufacturers may use the antigenically
equivalent A/Hiroshima/52/2005 virus; for the B/Malaysia/2506/2004-like antigen, manufacturers may
use the antigenically equivalent B/Ohio/1/2005 virus. A link to this report and other information can be
accessed at http://www.cdc.gov/flu.
American College of Cardiology, American Heart Association Task Force on Practice Guidelines,
Society of Cardiovascular Anesthesiologists, Society for Cardiovascular AI, Society of Thoracic
Surgeons, Bonow RO, et al. ACC/AHA 2006 guidelines for the management of patients with
valvular heart disease: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (writing Committee to Revise the 1998
guidelines for the management of patients with valvular heart disease) developed in
collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for
Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Journal
of the American College of Cardiology 48(3) 2006: 1.
American Heart Association Nutrition Committee, Lichtenstein AH, Appel LJ, Brands M, Carnethon M,
Daniels S, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from
the American Heart Association Nutrition Committee.[erratum appears in Circulation. 2006 Jul
4;114(1):e27]. Circulation 114(1) 2006: 82-96.
Improving diet and lifestyle is a critical component of the American Heart Association's strategy for
5
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
cardiovascular disease risk reduction in the general population. This document presents
recommendations designed to meet this objective. Specific goals are to consume an overall healthy diet;
aim for a healthy body weight; aim for recommended levels of low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol, and triglycerides; aim for normal blood pressure; aim for a normal blood
glucose level; be physically active; and avoid use of and exposure to tobacco products. The
recommendations are to balance caloric intake and physical activity to achieve and maintain a healthy
body weight; consume a diet rich in vegetables and fruits; choose whole-grain, high-fiber foods;
consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7% of energy,
trans fat to <1% of energy, and cholesterol to <300 mg/day by choosing lean meats and vegetable
alternatives, fat-free (skim) or low-fat (1% fat) dairy products and minimize intake of partially
hydrogenated fats; minimize intake of beverages and foods with added sugars; choose and prepare
foods with little or no salt; if you consume alcohol, do so in moderation; and when you eat food prepared
outside of the home, follow these Diet and Lifestyle Recommendations. By adhering to these diet and
lifestyle recommendations, Americans can substantially reduce their risk of developing cardiovascular
disease, which remains the leading cause of morbidity and mortality in the United States.
American Medical Directors Association (AMDA). Sleep disorders. Columbia: AMDA, 2006. URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9381
[last accessed: 13
September 2006].
American Medical Directors Association (AMDA). Gastrointestinal disorders. Columbia: AMDA,
2006.
URL:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9380
[last
accessed: 13 September 2006].
Angelini C, Federico A, Reichmann H, Lombes A, Chinnery P, Turnbull D. Task force guidelines
handbook: EFNS guidelines on diagnosis and management of fatty acid mitochondrial
disorders. European Journal of Neurology 13(9) 2006: 923-929.
Guidelines in the diagnosis and current dietary treatment of long-chain fatty acid (LCFA) defects have
been collected according to evidence-based medicine. Since the identification of carnitine and carnitine
palmitoyltransferase deficiency more than 25 years ago, nearly every enzymatic step required for betaoxidation has been associated with an inherited metabolic disorder. These disorders effectively preclude
the use of body fat as an energy source. Clinical consequences can range from no symptoms to severe
manifestations including cardiomyopathy, hypoglycaemia, peripheral neuropathy and sudden death. A
diet high in carbohydrates, diet with medium-chain triglycerides and reduced amount of LCFA has a
beneficial effect (class IV evidence) and in appropriate deficiency states carnitine and riboflavin are used
(good practice points).
Anonymous. Diabetic peripheral neuropathic pain. Consensus guidelines for treatment. Journal
of Family Practice. Suppl 2006.
Canadian Paediatric Society (CPS). Current management of herpes simplex virus infection in
pregnant
women
and
their
newborn
infants.
CPS,
2006.
URL:
http://www.cps.ca/english/statements/ID/ID06-03.htm [last accessed: 13 September 2006].
Dart R, Erdman A, Olson K, Christianson G, Manoguerra A, Chyka P, et al. Acetaminophen
poisoning: An evidence-based consensus guideline for out-of-hospital management. Clinical
Toxicology: The Official Journal of the American Academy of Clinical Toxicology & European
Association of Poisons Centres & Clinical Toxicologists 44(1) 2006: 1-18.
The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital
triage and initial management of patients with suspected ingestions of acetaminophen. An evidencebased expert consensus process was used to create this guideline. This guideline applies to ingestion of
acetaminophen alone and is based on an assessment of current scientific and clinical information. The
expert consensus panel recognizes that specific patient care decisions may be at variance with this
guideline and are the prerogative of the patient and the health professionals providing care. The panel's
recommendations follow. These recommendations are provided in chronological order of likely clinical
use. The grade of recommendation is provided in parentheses. 1) The initial history obtained by the
specialist in poison information should include the patient's age and intent (Grade B), the specific
formulation and dose of acetaminophen, the ingestion pattern (single or multiple), duration of ingestion
6
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
(Grade B), and concomitant medications that might have been ingested (Grade D). 2) Any patient with
stated or suspected self-harm or who is the recipient of a potentially malicious administration of
acetaminophen should be referred to an emergency department immediately regardless of the amount
ingested. This referral should be guided by local poison center procedures (Grade D). 3) Activated
charcoal can be considered if local poison center policies support its prehospital use, a toxic dose of
acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion (Grade A).
Gastrointestinal decontamination could be particularly important if acetylcysteine cannot be administered
within 8 hours of ingestion. Acute, single, unintentional ingestion of acetaminophen: 1) Any patient with
signs consistent with acetaminophen poisoning (e.g., repeated vomiting, abdominal tenderness in the
right upper quadrant or mental status changes) should be referred to an emergency department for
evaluation (Grade D). 2) Patients less than 6 years of age should be referred to an emergency
department if the estimated acute ingestion amount is unknown or is 200 mg/kg or more. Patients can be
observed at home if the dose ingested is less than 200 mg/kg (Grade B). 3) Patients 6 years of age or
older should be referred to an emergency department if they have ingested at least 10 g or 200 mg/kg
(whichever is lower) or when the amount ingested is unknown (Grade D). 4) Patients referred to an
emergency department should arrive in time to have a stat serum acetaminophen concentration
determined at 4 hours after ingestion or as soon as possible thereafter. If the time of ingestion is
unknown, the patient should be referred to an emergency department immediately (Grade D). 5) If the
initial contact with the poison center occurs more than 36 hours after the ingestion and the patient is well,
the patient does not require further evaluation for acetaminophen toxicity (Grade D). Repeated
supratherapeutic ingestion of acetaminophen (RSTI): 1) Patients under 6 years of age should be referred
to an emergency department immediately if they have ingested: a) 200 mg/kg or more over a single 24hour period, or b) 150 mg/kg or more per 24-hour period for the preceding 48 hours, or c) 100 mg/kg or
more per 24-hour period for the preceding 72 hours or longer (Grade C). 2) Patients 6 years of age or
older should be referred to an emergency department if they have ingested: a) at least 10 g or 200
mg/kg (whichever is less) over a single 24-hour period, or b) at least 6 g or 150 mg/kg (whichever is less)
per 24-hour period for the preceding 48 hours or longer. In patients with conditions purported to increase
susceptibility to acetaminophen toxicity (alcoholism, isoniazid use, prolonged fasting), the dose of
acetaminophen considered as RSTI should be greater than 4 g or 100 mg/kg (whichever is less) per day
(Grade D). 3) Gastrointestinal decontamination is not needed (Grade D). Other recommendations: 1)
The out-of-hospital management of extended-release acetaminophen or multi-drug combination products
containing acetaminophen is the same as an ingestion of acetaminophen alone (Grade D). However, the
effects of other drugs might require referral to an emergency department in accordance with the poison
center's normal triage criteria. 2) The use of cimetidine as an antidote is not recommended (Grade A).
Devogelaer JP, Goemaere S, Boonen S, Body JJ, Kaufman JM, Reginster JY, et al. Evidence-based
guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a
consensus document of the Belgian Bone Club. Osteoporosis International 17(1) 2006: 8-19.
Glucocorticoids (GCs) are frequently prescribed for various inflammatory and/or life-threatening
conditions concerning many systems in the body. However, they can provoke many aftereffects, of which
osteoporosis (OP) is one of the most crippling complications, with its host of fractures. The dramatic
increase in bone fragility is mainly attributable to the GC-induced rapid bone loss in all skeletal
compartments. We have reviewed the meta-analyses and randomized controlled studies reporting
medical therapeutic interventions currently registered in Belgium for the management of GC-OP
comparatively with a placebo. Based on this research, an expert meeting developed a consensus on the
prevention and therapy of GC-OP. The pathophysiology of GC-OP is complex. Several factors, acting
separately or synergistically, have been described. Their great number could help to understand the
rapidity of bone loss and of bone fragility occurrence, indicating that a rapid therapeutic intervention
should be implemented to avoid complications. All patients on GCs are threatened with OP, so the
prevention and/or therapy of GC-OP should be considered not only for postmenopausal females, but
also for osteopenic premenopausal females and for males put on a daily dose of at least 7.5 mg
equivalent prednisolone that is expected to last at least 3 months. Non-pharmacological interventions,
such as exercise and avoidance of tobacco and alcohol, should be recommended, even if their role is
not definitely settled in GC-OP prevention. Supplemental calcium and vitamin D should be considered as
the first-line therapy because of the decrease in intestinal calcium absorption provoked by GCs. They
also could be considered either as isolated therapy in patients taking less than 7.5 mg prednisolone daily
and/or for a predicted period shorter than 3 months or as adjuvant therapy to other more potent drugs.
Hormone replacement therapy could be considered in young postmenopausal females on GC, such as
in postmenopausal OP, or in men with low androgen levels. Calcitonin appears to have a protective
effect on trabecular bone in GC-OP, just as in postmenopausal OP. There is an increasing body of
evidence supporting the antifracture efficacy of bisphosphonates, notably alendronate and risedronate.
Preventative and curative therapy of GC-OP should be maintained as long as the patient is on GC
treatment and could be stopped after weaning from GC, because there is more than circumstantial
evidence of some recovery of BMD when GCs are stopped. There is no indication in GC-OP for any
7
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
combination of two antiresorptive agents (except for calcium and vitamin D) or for an antiresorptive and
an anabolic agent. There is indeed no proof that the increased costs of combined treatments will
translate into increased therapeutic efficacy. [References: 98]
Elder G, Faull R, Branley P, Hawley C, Caring for Australasians with Renal I. The CARI guidelines.
Management of bone disease, calcium, phosphate and parathyroid hormone. Nephrology 11(1)
2006.
Erdine S, Ari O. ESH-ESC guidelines for the management of hypertension. Herz 31(4) 2006: 331338.
The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European
Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous
relationship between the level of blood pressure and cardiovascular risk makes the definition of
hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be
made and decision about the management should not be based on blood pressure alone, but also
according to the presence or absence of other risk factors, target organ damage, diabetes, and
cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social
situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used
as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable
variability of office blood pressure is found over the same or different visits, high office blood pressure is
measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between
blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or
research is involved. Secondary hypertension should always be investigated. The primary goal of
treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk
of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified,
including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical
conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence
from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively
lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive
patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever
appropriate in all patients, including subjects with high normal blood pressure and patients who require
drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical
conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and
target blood pressure achieved progressively through several weeks. To reach target blood pressure, it
is likely that a large proportion of patients will require combination therapy with more than one agent. The
main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also
evidence that specific drug classes may differ in some effect or in special groups of patients. The choice
of drugs will be influenced by many factors, including previous experience of the patient with
antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical
cardiovascular or renal disease or diabetes, patient's preference.
Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006
Guidelines for the Management of Patients With Atrial Fibrillation. A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
European Society of Cardiology Committee for Practice Guidelines (Writing Committee to
Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). Journal of
the American College of Cardiology 48(4) 2006: e149-e246.
Gilron I, Watson CPN, Cahill CM, Moulin DE. Neuropathic pain: A practical guide for the clinician.
CMAJ: Canadian Medical Association Journal 175(3) 2006: 265-275.
Neuropathic pain, caused by various central and peripheral nerve disorders, is especially problematic
because of its severity, chronicity and resistance to simple analgesics. The condition affects 2%-3% of
the population, is costly to the health care system and is personally devastating to the people who
experience it. The diagnosis of neuropathic pain is based primarily on history (e.g., underlying disorder
and distinct pain qualities) and the findings on physical examination (e.g., pattern of sensory
disturbance); however, several tests may sometimes be helpful. Important pathophysiologic mechanisms
include sodium- and calcium-channel upregulation, spinal hyperexcitability, descending facilitation and
aberrant sympathetic-somatic nervous system interactions. Treatments are generally palliative and
include conservative non-pharmacologic therapies, drugs and more invasive interventions (e.g., spinal
8
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
cord stimulation). Individualizing treatment requires consideration of the functional impact of the
neuropathic pain (e.g., depression, disability) as well as ongoing evaluation, patient education,
reassurance and specialty referral. We propose a primary care algorithm for treatments with the most
favourable risk-benefit profile, including topical lidocaine, gabapentin, pregabalin, tricyclic
antidepressants, mixed serotonin-norepinephrine reuptake inhibitors, tramadol and opioids. The field of
neuropathic pain research and treatment is in the early stages of development, with many unmet goals.
In coming years, several advances are expected in the basic and clinical sciences of neuropathic pain,
which will provide new and improved therapies for patients who continue to experience this disabling
condition.
Harris D, Thomas M, Johnson D, Nicholls K, Gillin A, Caring for Australasians with Renal Impairment.
The CARI guidelines. Prevention of progression of kidney disease. Nephrology 11(1) 2006.
Hommes DW, Oldenburg B, van Bodegraven AA, van Hogezand RA, de Jong DJ, Romberg-Camps
MJL, et al. Guidelines for treatment with infliximab for Crohn's disease. Netherlands Journal of
Medicine 64(7) 2006: 219-229.
Infliximab is an accepted induction and maintenance treatment for patients with Crohn's disease. The
effectiveness of infliximab has been demonstrated for both active luminal disease and for
enterocutaneous fistulisation. In addition, infliximab can be administered for extraintestinal symptoms of
Crohn's disease, such as pyoderma gangrenosum, uveitis and arthropathy. Maintenance treatment with
infliximab is effective and is regarded as safe as long as the necessary safety measures are heeded.
Infusion reactions occur in 3 to 17% of the patients and are associated with the formation of antibodies to
infliximab. A reduction in infusion reactions is possible by the concurrent administration of steroids and
the use of immunosuppressants (azathioprine, G-mercaptopurine, methotrexate). Furthermore,
immunosuppressants increase the duration of the response to infliximab. For these reasons, the
concomitant use of immunosuppressants with infliximab is recommended. Infections and most
specifically tuberculosis need to be ruled out before infliximab is administered. Up to now, there are no
indications for a connection between an increased risk for malignancies and treatment with infliximab.
Institute for Clinical Systems Improvement (ICSI). Lipid management in adults. Bloomington: ICSI,
2006. URL; http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=197 [last accessed: 13
September 2006].
Kienle GS, Kiene H, Albonico HU. Anthroposophic medicine: Health Technology Assessment
Report - Short version. Forschende Komplementarmedizin 13(2) 2006: 7-18.
Background and Objective: The aim of this Health Technology Assessment Report was to analyse the
current situation, efficacy, effectiveness, safety, utilization, and costs of Anthroposophic Medicine (AM)
with special emphasis on everyday practice. Design: Systematic review. Material and Methods: Search
of 20 databases, reference lists and expert consultations. Criteria-based analysis was performed to
assess methodological quality and external validity of the studies. Results: AM is a complementary
medical system that extends conventional medicine and provides specific pharmacological and nonpharmacological treatments. It covers all areas of medicine. 178 clinical trials on efficacy and
effectiveness were identified: 17 RCTs, 21 prospective and 43 retrospective NRCTs, 50 prospective and
47 retrospective cohort studies/case-series without control groups. They investigated a wide range of
AM-treatments in a variety of diseases, 90 x mistletoe in cancer. 170 trials had a positive result for AM.
Methodological quality differed substantially; some studies showed major limitations, others were
reasonably well conducted. Trials of better quality still showed a positive result. External validity was
usually high. Side effects or other risks are rare. AM-patients are well educated, often female, aged 3050 years, or children. The few economic investigations found less or equal costs in AM because of
reduced hospital admissions and less prescriptions of medications. Conclusion: Trials of varying design
and quality in a variety of diseases predominantly describe good clinical outcome for AM, little side
effects, high satisfaction of patients and presumably slightly less costs. More research and more
methodological expertise and infrastructure are desirable.
Lahrmann H, Cortelli P, Hilz M, Mathias CJ, Struhal W, Tassinari M. EFNS guidelines on the
diagnosis and management of orthostatic hypotension. European Journal of Neurology 13(9)
2006: 930-936.
Orthostatic (postural) hypotension (OH) is a common, yet under diagnosed disorder. It may contribute to
9
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
disability and even death. It can be the initial sign, and lead to incapacitating symptoms in primary and
secondary autonomic disorders. These range from visual disturbances and dizziness to loss of
consciousness (syncope) after postural change. Evidence based guidelines for the diagnostic workup
and the therapeutic management (non-pharmacological and pharmacological) are provided based on the
EFNS guidance regulations. The final literature research was performed in March 2005. For diagnosis of
OH, a structured history taking and measurement of blood pressure (BP) and heart rate in supine and
upright position are necessary. OH is defined as fall in systolic BP below 20 mmHg and diastolic BP
below 10 mmHg of baseline within 3 min in upright position. Passive head-up tilt testing is recommended
if the active standing test is negative, especially if the history is suggestive of OH, or in patients with
motor impairment. The management initially consists of education, advice and training on various factors
that influence blood pressure. Increased water and salt ingestion effectively improves OH. Physical
measures include leg crossing, squatting, elastic abdominal binders and stockings, and careful exercise.
Fludrocortisone is a valuable starter drug. Second line drugs include sympathomimetics, such as
midodrine, ephedrine, or dihydroxyphenylserine. Supine hypertension has to be considered.
Lang A, Froelicher ES. Management of overweight and obesity in adults: behavioral intervention
for long-term weight loss and maintenance. European Journal of Cardiovascular Nursing. 5(2)
2006: 102-14. (61 ref).
BACKGROUND: The World Health Organization has identified obesity as a global epidemic. While
weight loss is a considerable challenge, long-term maintenance of weight loss is an even greater
problem. AIMS: This review of the assessment and management of overweight and obesity in adults
covers factors contributing to overweight and obesity, components of weight-loss management, and
interventions and effects of behavioral treatment for long-term weight loss and maintenance. METHODS:
A thorough search of the medical and nursing literature recorded in the MEDLINE database from 1995 to
2003 was conducted by using the keywords "overweight", "obesity", and "behavioral therapy".
RESULTS: Obesity is a complex, multifaceted condition in which excessive body fat places a person at
risk of multiple health problems. Excessive body fat results from energy intake that exceeds energy
expenditure. CONCLUSIONS: Increasing evidence suggests that obesity is not simply a problem of will
power or self-control but a complex disorder involving appetite regulation and energy metabolism that is
associated with a variety of comorbid conditions. Effective strategies of weight loss require management
strategies in a combined approach of dietary therapy and physical activity by using behavioral
interventions.
McDermott AY, Mernitz H. Exercise and older patients: Prescribing guidelines. American Family
Physician 74(3) 2006: 437-444.
A combination of aerobic activity, strength training, and flexibility exercises, plus increased general daily
activity can reduce medication dependence and health care costs while maintaining functional
independence and improving quality of life in older adults. However, patients often do not benefit fully
from exercise prescriptions because they receive vague or inappropriate instructions. Effective exercise
prescriptions include recommendations on frequency, intensity, type, time, and progression of exercise
that follow disease-specific guidelines. Changes in physical activity require multiple motivational
strategies including exercise instruction as well as goal-setting, self-monitoring, and problem-solving
education. Helping patients identify emotionally rewarding and physically appropriate activities,
contingencies, and social support will increase exercise continuation rates and facilitate desirable health
outcomes. Through patient contact and community advocacy, physicians can promote lifestyle patterns
that are essential for healthy aging.
Mrowietz U, Barth J, Boehncke W-H, Reich K, Rosenbach T, V. S, et al. Guideline: Therapy of
psoriasis vulgaris with efalizumab. Journal der Deutschen Dermatologischen Gesellschaft 4(6)
2006: 511-512.
North American Menopause Society. Management of osteoporosis in postmenopausal women:
2006 position statement of The North American Menopause Society. Menopause 13(3) 2006:
340-67.
OBJECTIVE: To update the evidence-based position statement published by The North American
Menopause Society (NAMS) in 2002 regarding the management of osteoporosis in postmenopausal
women. DESIGN: NAMS followed the general principles established for evidence-based guidelines to
create this updated document. A panel of clinicians and researchers expert in the field of metabolic bone
10
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
diseases and/or women's health were enlisted to review the 2002 NAMS position statement, compile
supporting statements, and reach consensus on recommendations. The panel's recommendations were
reviewed and approved by the NAMS Board of Trustees. RESULTS: Osteoporosis, whose prevalence is
especially high among elderly postmenopausal women, increases the risk of fractures. Hip and spine
fractures are associated with particularly high morbidity and mortality in this population. Given the health
implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures,
which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or
eliminating factors that may contribute to fractures. The evaluation of postmenopausal women for
osteoporosis risk requires a medical history, physical examination, and diagnostic tests. Major risk
factors for postmenopausal osteoporosis (as defined by bone mineral density) include advanced age,
genetics, lifestyle factors (such as low calcium and vitamin D intake, smoking), thinness, and menopause
status. The most common risk factors for osteoporotic fracture are advanced age, low bone mineral
density, and previous fracture as an adult. Management focuses first on nonpharmacologic measures,
such as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation,
avoidance of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated,
government-approved options are bisphosphonates, a selective estrogen-receptor modulator,
parathyroid hormone, estrogens, and calcitonin. CONCLUSIONS: Management strategies for
postmenopausal women involve identifying those at risk of low bone density and fracture, followed by
instituting measures that focus on reducing modifiable risk factors through lifestyle changes and, if
indicated, pharmacologic therapy. [References: 234]
Schofer H, Brockmeyer NH. Short guideline for Kaposi's sarcoma. Journal der Deutschen
Dermatologischen Gesellschaft 4(7) 2006: 586-590.
Seebacher C, Abeck D, Brasch J, Effendy I, Ginter-Hanselmayer G, Haake N, et al. Guideline for
candidosis of the skin. Journal der Deutschen Dermatologischen Gesellschaft 4(7) 2006: 591-596.
Senese V, Hendricks MB, Morrison M, Harris J. SUNA clinical practice guidelines: suprapubic
catheter replacement. Urologic Nursing. 26(3) 2006: 225-6. (7 ref).
Skeie GO, Apostolski S, Evoli A, Gilhus NE, Hart IK, Harms L, et al. Guidelines for the treatment of
autoimmune neuromuscular transmission disorders. European Journal of Neurology 13(7) 2006:
691-9.
Important progress has been made in our understanding of the cellular and molecular processes
underlying the autoimmune neuromuscular transmission (NMT) disorders; myasthenia gravis (MG),
Lambert-Eaton myasthenic syndrome (LEMS) and neuromyotonia (peripheral nerve hyperexcitability;
Isaacs syndrome). To prepare consensus guidelines for the treatment of the autoimmune NMT
disorders. References retrieved from MEDLINE, EMBASE and the Cochrane Library were considered
and statements prepared and agreed on by disease experts and a patient representative. The proposed
practical treatment guidelines are agreed upon by the Task Force: (i) Anticholinesterase drugs should be
the first drug to be given in the management of MG (good practice point). (ii) Plasma exchange is
recommended as a short-term treatment in MG, especially in severe cases to induce remission and in
preparation for surgery (level B recommendation). (iii) Intravenous immunoglobulin (IvIg) and plasma
exchange are equally effective for the treatment of MG exacerbations (level A Recommendation). (iv)
For patients with non-thymomatous autoimmune MG, thymectomy (TE) is recommended as an option to
increase the probability of remission or improvement (level B recommendation). (v) Once thymoma is
diagnosed TE is indicated irrespective of the severity of MG (level A recommendation). (vi) Oral
corticosteroids is a first choice drug when immunosuppressive drugs are necessary in MG (good practice
point). (vii) In patients where long-term immunosuppression is necessary, azathioprine is recommended
together with steroids to allow tapering the steroids to the lowest possible dose whilst maintaining
azathioprine (level A recommendation). (viii) 3,4-diaminopyridine is recommended as symptomatic
treatment and IvIg has a positive short-term effect in LEMS (good practice point). (ix) All neuromyotonia
patients should be treated symptomatically with an anti-epileptic drug that reduces peripheral nerve
hyperexcitability (good practice point). (x) Definitive management of paraneoplastic neuromyotonia and
LEMS is treatment of the underlying tumour (good practice point). (xi) For immunosuppressive treatment
of LEMS and NMT it is reasonable to adopt treatment procedures by analogy with MG (good practice
point).
Smith Jr SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC Guidelines for
Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease:
2006 Update. Endorsed by the National Heart, Lung, and Blood Institute. Journal of the American
11
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
College of Cardiology 47(10) 2006: 2130-2139.
Steiner M, Pearlstein T, Cohen LS, Endicott J, Kornstein SG, Roberts C, et al. Expert guidelines for
the treatment of severe PMS, PMDD, and comorbidities: the role of SSRIs. Journal of Women's
Health (Larchmont). 15(1) 2006: 57-69.
The hallmark feature of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) is
the predictable, cyclic nature of symptoms or distinct on/offness that begins in the late luteal phase of the
menstrual cycle and remits shortly after the onset of menstruation. PMDD is distinguished from PMS by
the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in
personal relationships and marital/family domains. Several treatment modalities are beneficial in PMDD
and severe PMS, but the selective serotonin reuptake inhibitors (SSRIs) have emerged as first-line
therapy. The SSRIs can be administered continuously throughout the entire month, intermittently from
ovulation to the onset of menstruation, or semi-intermittently with dosage increases during the late luteal
phase. These guidelines present practical treatment algorithms for the use of SSRIs in women with pure
PMDD or severe PMS, PMDD and underlying subsyndromal clinical features of mood or anxiety, or
premenstrual exacerbation of a mood/anxiety disorder.
Vascular Access Work Group. Clinical practice guidelines for vascular access. American Journal
of Kidney Diseases 48(1) 2006.
Back to the Contents page
Cancer Care/Palliative Care
Ajani J, Bekaii-Saab T, D'Amico TA, Fuchs C, Gibson MK, Goldberg M, et al. Gastric Cancer Clinical
Practice Guidelines. Journal of the National Comprehensive Cancer Network 4(4) 2006: 350-66.
Ajani J, Bekaii-Saab T, D'Amico TA, Fuchs C, Gibson MK, Goldberg M, et al. Esophageal Cancer
Clinical Practice Guidelines. Journal of the National Comprehensive Cancer Network 4(4) 2006:
328-47.
Ajani J, Bekaii-Saab T, D'Amico TA, Fuchs C, Gibson MK, Goldberg M, et al. Gastric cancer: Clinical
Practice Guidelines in oncology. Journal of the National Comprehensive Cancer Network 4(4) 2006:
350-366.
Gastric cancer is rampant in several countries worldwide. Its incidence in the Western hemisphere has
been declining for more than 40 years; however, the location of gastric cancer has shifted proximally in
the past 15 years. The reason for this shift is unclear. Diffuse histology is also more common now than
intestinal type of histology. Advances have been made in staging procedures, such as laparoscopy and
endoscopic ultrasonography, and in possible functional imaging techniques. The current TNM
classification requires an examination of at least 15 lymph nodes; a DO dissection is unacceptable.
Patients with locoregional gastric carcinoma should also be referred to high-volume treatment centers.
Combination chemotherapy and radiotherapy in the adjuvant setting for a select group of patients is the
new standard in the United States. These guidelines provide a uniform systematic approach to gastric
cancer in the United States. Investigation results for new chemotherapeutic agents, including
antireceptor agents, vaccines, gene therapy, and antiangiogenic agents, and many future advances in
the treatment of gastric carcinoma are anticipated.
Ajani J, Bekaii-Saab T, D'Amico TA, Fuchs C, Gibson MK, Goldberg M, et al. Esophageal cancer:
Clinical Practice Guidelines in oncology. Journal of the National Comprehensive Cancer Network
4(4) 2006: 328-347.
Esophageal cancer is a major health hazard in many parts of the world. The incidence of
adenocarcinoma is increasing in white men, particularly in the nonendemic areas such as North America
and many Western European countries. Barrett's metaplasia, gastroesophageal reflux, hiatal hernia, and
12
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
obesity are believed to be contributing factors. In addition, the most common location of esophageal
carcinoma has shifted to the lower third of the esophagus. Unfortunately, esophageal carcinoma is often
diagnosed late and, therefore, most therapeutic approaches are palliative. Advances have been made in
staging procedures and therapeutic approaches. The guidelines emphasize that palpable advances have
been made in the treatment of locoregional esophageal carcinoma. Similarly, endoscopic palliation of
esophageal carcinoma has improved substantially because of improving technology. New
chemotherapeutic agents are on the horizon, including antireceptor agents, vaccines, gene therapy, and
anti-angiogenic agents. The panel expects numerous future advances in the treatment of esophageal
carcinoma.
American Society of Clinical Oncology, Pfister DG, Laurie SA, Weinstein GS, Mendenhall WM,
Adelstein DJ, et al. American Society of Clinical Oncology clinical practice guideline for the use
of larynx-preservation strategies in the treatment of laryngeal cancer. Journal of Clinical
Oncology 24(22) 2006: 3693-704.
PURPOSE: To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of
preserving the larynx (either the organ itself or its function). This guideline is intended for use by
oncologists in the care of patients outside of clinical trials. METHODS: A multidisciplinary Expert Panel
determined the clinical management questions to be addressed and reviewed the literature available
through November 2005, with emphasis given to randomized controlled trials of site-specific disease.
Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline
underwent internal review and approval by the Panel, as well as external review by additional experts,
members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the
ASCO Board of Directors. RESULTS: Evidence supports the use of larynx-preservation approaches for
appropriately selected patients without a compromise in survival; however, no larynx-preservation
approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with
rehabilitation as indicated. RECOMMENDATIONS: All patients with T1 or T2 laryngeal cancer, with rare
exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4
disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an
appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely
applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are
necessary, and the team should fully discuss with the patient the advantages and disadvantages of
larynx-preservation options compared with treatments that include total laryngectomy.
Clark OH, Ajani J, Benson IA, Byrd D, Doherty GM, Engstrom PF, et al. Neuroendocrine tumors:
Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network
4(2) 2006: 102-138.
Neuroendocrine tumors are relatively rare. An estimated 25,690 new cases of thyroid cancer will be
diagnosed in the United States in 2005, accounting for approximately 1% of all malignancies.
Neuroendocrine tumors can be broadly subdivided into tumors that are benign or malignant, functional
(i.e., producing a syndrome of hormonal excess) or nonfunctional. The management of neuroendocrine
tumors with surgical, medical, or radiation therapies is determined by the specific endocrine glands
involved, aggressiveness and stage of the tumor, hormonal concentrations detected, and specific patient
needs. These guidelines have been designed to address scenarios presented by 80% of patients and to
avoid scenarios relevant to less than 5% of patients.
Collie K, Bottorff JL, Long BC, Conati C. Distance art groups for women with breast cancer:
Guidelines and recommendations. Supportive Care in Cancer 14(8) 2006: 849-58.
To overcome barriers that prevent women with breast cancer from attending support groups, innovative
formats and modes of delivery both need to be considered. The present study was part of an
interdisciplinary program of research in which researchers from counseling psychology, psychooncology, nursing, computer science, and fine arts have explored art making as an innovative format and
telehealth as a mode of delivery. For this study, we conducted focus groups and interviews with 25
people with expertise about breast cancer, art, art therapy, and distance delivery of mental health
services to generate guidelines for distance art-based psychosocial support services to women with
breast cancer. A qualitative analysis of the focus group and interview data yielded guidelines for
developers and facilitators of distance art groups for women with breast cancer pertaining to (a)
emotional expression, (b) emotional support, (c) emotional safety, and (d) accommodating individual
differences, plus special considerations for art therapy groups. Further research is needed pertaining to
the use of computers, involvement of art therapists, and screening out vulnerable clients.
13
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
Hauschild A, Garbe C, Titler M. Short guideline - Cutaneous neuroendocrine carcinoma (Merkel
cell carcinoma). Journal der Deutschen Dermatologischen Gesellschaft 4(6) 2006: 508-510.
Hoppe RT, Advani RH, Bierman PJ, Bloomfield CD, Buadi F, Djulgegovic B, et al. Hodgkin
disease/lymphoma: Clinical practice guidelines in oncology. Journal of the National
Comprehensive Cancer Network 4(3) 2006: 210-230.
The management of HD continues to evolve, and the NCCN guidelines have undergone major changes
since their inception. Current management programs are based on comprehensive clinical staging
followed by combined modality therapy for patients with favorable and intermediate prognosis, or
chemotherapy alone for patients with advanced disease. Relapse is uncommon, but secondary
management with peripheral stem cell transplantation may be effective. The excellent prognosis for
these patients mandates careful long-term follow-up to detect late treatment effects.
Johnson BE, Crawford J, Downey RJ, Ettinger DS, Fossella F, Grecula JC, et al. Small cell lung
cancer: Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer
Network 4(6) 2006: 602-622.
In 2005, approximately 26,000 new cases of small cell lung cancer were diagnosed in the United States.
When compared with non-small cell lung cancer, SCLC generally has a more rapid doubling time, a
higher growth fraction, and earlier development of widespread metastases. SCLC is highly sensitive to
initial chemotherapy and radiotherapy. Treatment with chemotherapy plus chest radiotherapy can be
curative for some patients with limited-stage SCLC, whereas most patients with extensive-stage disease
who undergo chemotherapy alone experience palliated symptoms and prolonged survival. The updated
2006 NCCN guidelines include new principles of surgical resection as well as chemotherapy and
radiation dosage changes.
Levin B, Barthel JS, Burt RW, David DS, Ford JM, Giardiello FM, et al. Colorectal Cancer Screening
Clinical Practice Guidelines. Journal of the National Comprehensive Cancer Network 4(4) 2006:
384-420.
O'Donnell MR, Appelbaum FR, Baer MR, Byrd JC, Coutre SE, Damon LE, et al. Acute myeloid
leukemia: Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive
Cancer Network 4(1) 2006: 16-36.
Approximately 11,960 people will be diagnosed with acute myeloid leukemia (AML) in 2005, and 9,000
patients will die of the disease. As the population ages, the incidence of AML, along with myelodysplasia,
appears to be rising. Equally disturbing is the increasing incidence of treatment-related myelodysplasia
and leukemia in survivors of tumors of childhood and young adulthood such as Hodgkin's disease,
sarcomas, breast and testicular cancers, and lymphomas. Recent large clinical trials have highlighted
the need for new, innovative strategies because outcomes for AML patients, particularly older patients,
have not substantially changed in the past 3 decades.
Back to the Contents page
Mental Health and Learning Disabilities
American Psychiatric Association. Treatment of patients with eating disorders,third edition.
American Psychiatric Association. American Journal of Psychiatry 163(7 Suppl) 2006: 4-54.
Glauser T, Ben-Menachem E, Bourgeois B, Cnaan A, Chadwick D, Guerreiro C, et al. ILAE treatment
guidelines: Evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial
monotherapy for epileptic seizures and syndromes. Epilepsia 47(7) 2006: 1094-1120.
14
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
Purpose: To assess which antiepileptic medications (AEDs) have the best evidence for long-term
efficacy or effectiveness as initial monotherapy for patients with newly diagnosed or untreated epilepsy.
Methods: A 10-member subcommission of the Commission on therapeutic Strategies of The
International League Against Epilepsy (ILAE), including adult and pediatric epileptologists, clinical
pharmacologists, clinical trialists, and a statistician evaluated available evidence found through a
structured literature review including MEDLINE, Current Contents and the Cochrane Library for all
applicable articles from 1940 until July 2005. Articles dealing with different seizure types (for different
age groups) and two epilepsy syndromes were assessed for quality of evidence (four classes) based on
predefined criteria. Criteria for class I classification were a double-blind randomized controlled trial (RCT)
design, >=48-week treatment duration without forced exit criteria, information on >=24-week seizure
freedom data (efficacy) or >=48-week retention data (effectiveness), demonstration of superiority or 80%
power to detect a <=20% relative difference in efficacy/effectiveness versus an adequate comparator,
and appropriate statistical analysis. Class II studies met all class I criteria except for having either
treatment duration of 24 to 47 weeks or, for noninferiority analysis, a power to only exclude a 21-30%
relative difference. Class III studies included other randomized double-blind and open-label trials, and
class IV included other forms of evidence (e.g., expert opinion, case reports). Quality of clinical trial
evidence was used to determine the strength of the level of recommendation. Results: A total of 50
RCTs and seven meta-analyses contributed to the analysis. Only four RCTs had class I evidence,
whereas two had class II evidence; the remainder were evaluated as class III evidence. Three seizure
types had AEDs with level A or level B efficacy and effectiveness evidence as initial monotherapy: adults
with partial-onset seizures (level A, carbamazepine and phenytoin; level B, valproic acid), children with
partial-onset seizures (level A, oxcarbazepine; level B, None), and elderly adults with partial-onset
seizures (level A, gabapentin and lamotrigine; level B, one). One adult seizure type [adults with
generalized-onset tonic-clonic (GTC) seizures], two pediatric seizure types (GTC seizures and absence
seizures), and two epilepsy syndromes (benign epilepsy with centrotemporal spikes and juvenile
myoclonic epilepsy) had no AEDs with level A or level B efficacy and effectiveness evidence as initial
monotherapy. Conclusions: This evidence-based guideline focused on AED efficacy or effectiveness as
initial monotherapy for patients with newly diagnosed or untreated epilepsy. The absence of rigorous
comprehensive adverse effects data makes it impossible to develop an evidence-based guideline aimed
at identifying the overall optimal recommended initial-monotherapy AED. There is an especially alarming
lack of well-designed, properly conducted RCTs for patients with generalized seizures/epilepsies and for
children in general. The majority of relevant existing RCTs have significant methodologic problems that
limit their applicability to this guideline's clinically relevant main question. Multicenter, multinational efforts
are needed to design, conduct and analyze future clinically relevant RCTs that can answer the many
outstanding questions identified in this guideline. The ultimate choice of an AED for any individual patient
with newly diagnosed or untreated epilepsy should include consideration of the strength of the efficacy
and effectiveness evidence for each AED along with other variables such as the AED safety and
tolerability profile, pharmacokinetic properties, formulations, and expense. When selecting a patient's
AED, physicians and patients should consider all relevant variables and not just efficacy and
effectiveness.
Grunze H, Kasper S, Goodwin G, Bowden C, Moller H-J, Akiskal H, et al. The World Federation of
Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar
disorders, part III: Maintenance treatment. World Journal of Biological Psychiatry 5(3) 2006: 12035.
As with the two preceding guidelines of this series, these practice guidelines for the pharmacological
maintenance treatment of bipolar disorder were developed by an international task force of the World
Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic
overview of all scientific evidence relating to maintenance treatment. The data used for these guidelines
were extracted from a MEDLINE and EMBASE search, from recent proceedings from key conferences
and various national and international treatment guidelines. The scientific justification of support for
particular treatments was categorised into four levels of evidence (A-D). As these guidelines are
intended for clinical use, the scientific evidence was not only graded, but also reviewed by the experts of
the task force to ensure practicality.
Keshavan MS, Roberts M, Wittmann D. Guidelines for clinical treatment of early course
schizophrenia. Current Psychiatry Reports 8(4) 2006: 329-334.
Several practice guidelines have been developed for the management of schizophrenia based on the
current evidence base, but only a few have focused on the early course of this illness. In this article, we
review the current literature on the approaches to management of early schizophrenia (ie, the prodromal,
psychotic, and recovery phases of this illness). The efficacy of psychosocial and antipsychotic agents in
15
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
the prodromal phase is an area of active research. Atypical antipsychotics are the mainstay of treatment
for stabilization of the acute psychotic phase. Effective approaches in the recovery phase include
combining medications with individual and family interventions, supported employment, assertive
community treatment, cognitive remediation, and social skills training. Although evidence-based
interventions have generated new optimism among those with the illness, more efforts are needed to
increase access to care in community settings
McKeith IG. Consensus guidelines for the clinical and pathologic diagnosis of dementia with
Lewy bodies (DLB): Report of the Consortium on DLB International Workshop. Journal of
Alzheimer's Disease 9(SUPPL. 3) 2006: 417-423.
Dementia with Lewy bodies (DLB) was considered to be an uncommon cause of dementia until improved
neuropathological staining methods for ubiquitin were developed in the late 1980's. Subsequent
recognition that 10-15% of dementia cases in older people were associated with Lewy body pathology
led to the publication in 1996 of Consensus clinical and pathological diagnostic criteria for the disorder.
These have greatly raised global awareness of DLB and helped to generate a body of knowledge which
informs modern clinical management of this pharmacologically sensitive group of patients. They have
also enabled important issues surrounding the relationships of DLB with Alzheimer's disease and
Parkinson's disease to be addressed and partially resolved. A recent re-evaluation of the Consensus
criteria has confirmed many aspects of the original recommendations, supplementing these with
suggestions for improved pathological characterisation, clinical detection and management. Virtu-ally
unrecognised 20 years ago, DLB could within this decade be one of the best characterised and
potentially treatable neurodegenerative disorders of late life.
Morana HCP, Cgmara FP. International guidelines for the management of personality disorders.
Current Opinion in Psychiatry 19(5) 2006: 539-543.
PURPOSE OF REVIEW: Individuals with personality disorders have difficulties in finding specific
institutions or services that are designated to bind this kind of problem. These are people who are
required to go through many diagnoses and consult many professionals before someone produces the
correct diagnosis for their condition. This article reviews the new evidence in the management of
personality disorders and incorporates reliable data to determine global clinical recommendations for
treatment. RECENT FINDINGS: This review suggests that, although pharmacotherapy forms the
cornerstone of the management, utilization of adjunctive psychosocial treatments and incorporation of a
model that involves a healthcare team are required to provide optimal management for patients with
personality disorders. SUMMARY: The authors related the experience obtained in the Personality
Disorder Ambulatory of the Department of Psychiatry of Sao Paulo University Medical School in the
handling of the people with personality disorders and proposed the use of gabapentin as a coactuator in
the treatment of persons with these conditions.
Rush AJ. Guidelines for the Treatment of Major Depression. In: Stein DJ, editor. The American
Psychiatric Publishing textbook of mood disorders. Washington, DC: American Psychiatric Publishing;
2006. p. 439-461.
(create) Until recent times, the medication management of major depressive disorder (MDD) was
relatively straightforward because only two classes of antidepressants were available: tricydic
antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Over the last two decades, a
plethora of new antidepressant monotherapies, as well as a seemingly endless range of possible drug
combinations, have led to a complex set of possible treatments. In this chapter, I review the concepts of
treatment options, guidelines, and algorithms for MDD and highlight issues in developing and
synthesizing the evidence and in implementing guidelines or algorithms. I provide a synopsis of
medication guidelines and algorithms for adults with psychotic and nonpsychotic MDD and discuss the
potential roles of psychotherapy in the treatment of MDD. The available evidence for the effectiveness of
guidelines for clinical depression is reviewed, and clinical factors that likely affect the adaptation and
potentially the effectiveness of these protocols are discussed. I conclude with comments on future
directions in the evolution, implementation, and evaluation of guidelines for MDD.
Stein DJ. Guidelines and algorithms for anxiety disorders: Evidence-based excellence or
garbage in, garbage out? Current Psychiatry Reports 8(4) 2006: 253-255.
Substance Abuse and Mental Health Services Administration (SAMHSA). Detoxification and
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Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
substance abuse treatment. Rockville: Substance Abuse and Mental Health Services Administration
(SAMHSA), 2006. URL: http://store.health.org/catalog/productDetails.aspx?ProductID=17398 [last
accessed: 13 September 2006].
Swinson P, et al. Management of Anxiety Disorders. Can J Psychiatry 51(Supp 2) 2006. URL
http://www.cpa-apc.org/Publications/CJP/supplements/july2006/anxiety_guidelines_2006.pdf
[last
accessed: 13 Septemner 2006].
Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on
Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric
Association. American Journal of Psychiatry 163(6 Suppl) 2006: 3-36.
Wynaden D, Landsborough I, McGowan S, Baigmohamad Z, Finn M, Pennebaker D. Best practice
guidelines for the administration of intramuscular injections in the mental health setting.
International Journal of Mental Health Nursing 15(3) 2006: 195-200.
Intramuscular injections are administered to mental health consumers in both the community and
hospital settings. Medications delivered by the intramuscular route assist consumers to live in the
community and enhance their ability to integrate and engage in community life. Although the practice of
giving intramuscular injections is routine for mental health nurses, the process is invasive and best
practice guidelines are not well developed. The aim of this study was to identify a best practice technique
for the administration of intramuscular injections in the mental health setting based on: (i) the
identification of 300 abstracts and a systematic review of 150 articles in the subject area; (ii) an
evaluation of current practice of 93 nurses; and (iii) the use of the newly developed technique with 96
consumers. The findings add significantly to the knowledge base on administering intramuscular
injections in the mental health setting. The identified best practice technique provides mental health
nurses with evidence-based guidelines, thus ensuring that the medication administered by intramuscular
injection provides the best possible outcomes for consumers.
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Dentistry
Misch CE, Goodacre CJ, Finley JM, Misch CM, Marinbach M, Dabrowsky T, et al. Consensus
conference panel report: crown-height space guidelines for implant dentistry-part 2. Implant
Dentistry 15(2) 2006: 113-21.
The International Congress of Oral Implantologists sponsored a consensus conference on the topic of
Crown Height Space on June 26-27, 2004 in Las Vegas, Nevada. The panel communicated on several
occasions before, during, and after the meeting, both as a group and among individuals. A consensus of
one opinion was not developed for most issues. However, general guidelines emerged related to the
topic. The following article is Part 2 of a summary of several of the guidelines that should be of benefit to
the profession at large. (Part 1 appeared in Implant Dentistry 2005;14:312-321.)
Back to the Contents page
Sexual Health, BBV and related Topics
ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 74. Antibiotic prophylaxis for
gynecologic procedures. Obstetrics & Gynecology 108(1) 2006: 225-34.
Surgical site inflection remains the most common surgical complication. Up to 5% of operative patients
will develop a surgical site infection leading to a longer hospital stay and increased cost. One of the
advances in infection control practices has been the selective use of antibiotic prophylaxis.
17
Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
However,antibiotic use, especially prophylactic antibiotic use, has been associated with the selection of
antibiotic-resistant bacteria. Indiscriminate use of prophylactic antibiotics for institutions as well as for
individual patients promotes this dangerous side eject. There are acknowledged consequences of
prophylactic antibiotic use for institutions as well as for individual patients. It is important for clinicians to
understand when antibiotic prophylaxis is indicated and when it is inappropriate. The purpose of this
document is to review the evidence for surgical site infection prevention and appropriate antibiotic
prophylaxis for gynecologic procedures.
Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted
diseases treatment guidelines, 2006. Morbidity & Mortality Weekly Report. Recommendations &
Reports 55(RR-11) 2006: 1-94.
These guidelines for the treatment of persons who have sexually transmitted diseases (STDs) were
developed by CDC after consultation with a group of professionals knowledgeable in the field of STDs
who met in Atlanta, Georgia, during April 19-21, 2005. The information in this report updates the
Sexually Transmitted Diseases Treatment Guidelines, 2002 (MMWR 2002;51[No. RR-6]). Included in
these updated guidelines are an expanded diagnostic evaluation for cervicitis and trichomoniasis; new
antimicrobial recommendations for trichomoniasis; additional data on the clinical efficacy of azithromycin
for chlamydial infections in pregnancy; discussion of the role of Mycoplasma genitalium and
trichomoniasis in urethritis/cervicitis and treatment-related implications; emergence of lymphogranuloma
venereum protocolitis among men who have sex with men (MSM); expanded discussion of the criteria
for spinal fluid examination to evaluate for neurosyphilis; the emergence of azithromycin- resistant
Treponema pallidum; increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM;
revised discussion concerning the sexual transmission of hepatitis C; postexposure prophylaxis after
sexual assault; and an expanded discussion of STD prevention approaches.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
considerations and recommendations on oocyte and ovarian cryopreservation. FIGO
Committee for the Ethical Aspects of Human Reproduction and Women's Health. International
Journal of Gynaecology & Obstetrics 92(3) 2006: 335-6.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
recommendations on multiple pregnancy and multifetal reduction. FIGO Committee for the
Ethical Aspects of Human Reproduction and Women's Health. International Journal of
Gynaecology & Obstetrics 92(3) 2006: 331-2.
FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical
guidelines on sex selection for non-medical purposes. FIGO Committee for the Ethical Aspects
of Human Reproduction and Women's Health. International Journal of Gynaecology & Obstetrics
92(3) 2006: 329-30.
Rachlis A, Angel J, Harris M, Lalonde R, Smaill F, Tremblay C, et al. Canadian consensus
recommendations for the optimal use of enfuvirtide in HIV/AIDS patients. The Canadian Journal
of Infectious Diseases & Medical Microbiology 17(3) 2006: 155-163.
BACKGROUND AND OBJECTIVES: An eight-member group consisting of Canadian infectious disease
and immunology specialists and a family physician with significant experience in HIV management was
convened to update existing recommendations, specifically intended for use by Canadian HIV-treating
physicians, on the appropriate use of enfuvirtide in HIV/AIDS patients with resistance to other
antiretroviral drugs. METHODS: Evidence from the literature and expert opinions of the group members
formed the basis of the guidelines. Comments on the draft guidelines were obtained from other
physicians across Canada with HIV expertise. The final guidelines represent the group's consensus
agreement. RESULTS AND CONCLUSIONS: The recommendations were developed to guide
physicians in optimal practices in patient selection for enfuvirtide treatment and subsequent patient
management. The issues considered include positive predictors of response to enfuvirtide, stage of
disease, optimization of the background regimen, early indicators of enfuvirtide response, and patient
education and support.
Serour GI. Ethical guidelines on iatrogenic and self-induced infertility. FIGO Committee for the
Ethical Aspects of Human Reproduction and Women's Health. International Journal of
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Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
Gynecology & Obstetrics 94(2) 2006: 172-173.
Serour GI. Ethical guidelines on resuscitation of newborns. FIGO Committee for the Ethical
Aspects of Human Reproduction and Women's Health. International Journal of Gynecology &
Obstetrics 94(2) 2006: 169-171.
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Child Health
Cross JH, Jayakar P, Nordli D, Delalande O, Duchowny M, Wieser HG, et al. Proposed criteria for
referral and evaluation of children for epilepsy surgery: recommendations of the
Subcommission for Pediatric Epilepsy Surgery. Epilepsia 47(6) 2006: 952-9.
The Commission on Neurosurgery of the International League Against Epilepsy (ILAE) formed the
Pediatric Epilepsy Surgery Subcommission in 1998 and charged it with formulating guidelines and
recommendations for epilepsy surgery in childhood. Also endorsed by the Commission on Paediatrics,
the following document is the consensus agreement after a meeting of 32 individuals from 12 countries
in 2003. The panel agreed that insufficient class 1 evidence exists to recommend practice guidelines at
this time. Instead, the panel generated criteria concerning the unique features of pediatric epilepsy
patients to justify dedicated resources for specialty pediatric surgical centers, suggested guidelines for
physicians for when to refer children with refractory epilepsy, and recommendations on presurgical
evaluation and postoperative assessments. The panel also outlined areas of agreement and
disagreement on which future research and consensus meetings should focus attention to generate
practice guidelines and criteria for pediatric epilepsy surgery centers.
Working Group of the Japanese Society for Pediatric Gastroenterology and Hepatology, Nutrition,
Konno M, Kobayashi A, Tomomasa T, Kaneko H, et al. Guidelines for the treatment of Crohn's
disease in children. Pediatrics International 48(3) 2006: 349-52.
This paper shows guidelines for the treatment of Crohn's disease in children by the Working Group of the
Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (Chair: Yuichiro Yamashiro)
and the Japanese Society for Pediatric Inflammatory Bowel Disease (Chair: Akio Kobayashi). The points
in which these guidelines differ from those for adult patients are as follows. (i) Total enteral nutrition in
the form of an elemental formula is indicated as primary therapy for children with Crohn's disease at
onset as well as the active stage. Oral mesalazine is used together. (ii) Total parenteral nutrition (TPN)
with oral mesalazine is required for children with serious illness. The use of a corticosteroid should be
withheld for at least 1 week after TPN has been started. (iii) When TPN is not considered to be effective,
additional corticosteroid is used. Full doses of corticosteroid should be used for at least 2 weeks after
clinical improvement has been achieved, and then the dose of the corticosteroid should be tapered
carefully. (iv) When surgery is indicated in pediatric patients with stricture or fistula formation and
complicated by persistent growth failure despite medical therapy, the optimum time for surgery is thought
to be before epiphyseal plates have been closed.
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Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
C. Guidelines Implementation
May C. Mobilising modern facts: Health technology assessment and the politics of evidence.
Sociology of Health & Illness 28(5) 2006: 513-532.
Conventional models of 'evidence' for clinical practice focus on the role of randomised controlled clinical
trials and systematic reviews as technologies that promote a specific model of rigor and analytic
accountability. The assumption that runs through the disciplinary field of health technology assessment
(HTA), for example, is that the quantification of evidence about cost and clinical effectiveness is central
to rational policy-making and healthcare provision. But what are the conditions in which such knowledge
is mediated into decision-making contexts, and how is it understood and used when it gets there? This
paper addresses these questions by examining a series of meetings and seminars attended by senior
clinical researchers, social care and health service managers in the UK between 1998-2004, and
sessions of the House of Commons Health Committee held in 2001 and 2005. These provide contexts in
which questions about the value and utility of evidence produced within the frame of HTA were explored
in relation to parallel questions about the design, evaluation and implementation of telemedicine and
telecare systems. The paper points to the ways that evidence generated in the normative frame of HTA
was increasingly seen as one-dimensional and medicalised knowledge that failed to respond to the
contingencies of everyday practice in health and social care settings.
Moret-Hartman M, Knoester PD, Hekster YA, van der Wilt GJ. Non-compliance on the part of the
professional community with a national guideline: An argumentative policy analysis. Health
Policy 78(2-3) 2006: 353-359.
In 1997, the National Health Insurance Board of the Netherlands (CVZ) introduced a guideline for the
use of a new anti-epileptic drug, Lamotrigine. The goal was to limit the use of this relatively expensive
drug to patients with difficult-to-treat epilepsy. A survey had shown that only a minority of neurologists
were familiar with the guideline, and even fewer applied it in practice. In the present study, interviews
were held with stakeholders to obtain a better understanding of why this policy measure failed. The
results indicate that the problem definitions of policy maker and practicing neurologists differed widely,
and that the policy measure was conflicting with certain professional beliefs. In such cases, the theory of
argumentative policy predicts that policy is unlikely to succeed, unless policy makers take actions to
ensure a greater congruence in interpretative frames between them and their target population.
Renzi PM, Ghezzo H, Goulet S, Dorval E, Thivierge RL. Paper stamp checklist tool enhances
asthma guidelines knowledge and implementation by primary care physicians. Canadian
Respiratory Journal 13(4) 2006: 193-7.
Background: The Canadian Clinical Practice Guidelines (CPGs) for the management of asthmatic
patients were last published in 1999, with updates in 2001 and June 2004. Large disparities exist in the
implementation of these guidelines into clinical practice. Objective: The present study evaluated the
knowlege of Quebec-based primary care physicians regarding the CPGs, as well as patient outcomes
before and after introducing physicians to a new clinical tool - a memory aid in the form of a self-inking
paper stamp checklist summarizing CPG criteria and guidelines for assessing asthmatic patient control
and therapy. The primary objective of the present study was to assess whether the stamp would improve
physicians' knowledge of the CPGs, and as a secondary objective, to assess whether it would decrease
patient emergency room visits and hospitalizations. Methods: A prospective, randomized, controlled
study of 104 primary care physicians located in four Quebec regions was conducted. Each physician
initially responded to questions on their knowledge of the CPGs, and was then randomly assigned to one
of four groups that received information about the CPGs while implementing an intervention (the stamp
tool) aimed at supporting their decision-making process at the point of care. Six months later, the
physicians were retested, and patient outcomes for approximately one year were obtained from the
Regie de l'assurance maladie du Quebec. Results: The stamp significantly improved physicians'
knowledge of the CPGs in all Quebec regions tested, and reduced emergency room visits and
hospitalizations in patients who were followed for at least one year. Conclusion: A paper stamp
summarizing CPGs for asthma can be used effectively to increase the knowledge of physicians and to
positively affect patient outcomes.
Vollmar HC, Schurer-Maly CC, Frahne J, Lelgemann M, Butzlaff M. An E-learning platform for
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Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.
guideline implementation: Evidence- and case-based knowledge translation via the internet.
Methods of Information in Medicine 45(4) 2006: 389-396.
Objectives: Effective knowledge translation in medicine is an essential element of a modern health care
system. Evidence-based clinical practice guidelines (CPGs) are considered relevant instruments for the
transfer of knowledge into clinical practice. To improve this transfer we have created Internet-based
continuing medical education (CME) modules and online case-based learning objects. Methods: Building
upon existing CPGs, an e-learning platform including a multi-step review process was developed to
generate CME modules. These CME modules were presented through a modified content management
system (CMS) that fulfils specific requirements of CME. An online questionnaire using a four-point Likert
scale was designed to receive mandatory feedback from participating physicians. In the second step of
development, case-based learning objects were added to the CMS. Results: Existing clinical practice
guidelines allowed a rapid development of CME modules specific to individual clinical indications. The
modified CMS proved to be technically stable but also resource-intensive. 3105 physicians registered
and used the platform between June 2003 and April 2005. 95% of the physicians expressed positive
feedback in an evaluation questionnaire; only 35% of physicians actually used the corresponding CPGs
in practice. Suggestions from the CME users led to the development of interactive medical case-based
learning objects related to the main topics of the CPGs. Conclusions: To support the implementation of
CPGs, an Internet platform for CME including case-based learning objects and examination tests was
developed. An interactive online CME platform can support active learning and may establish an
additional stimulus for knowledge translation into daily medical practice.
Winn RJ. Where are we headed: The value of updating guidelines. Journal of the National
Comprehensive Cancer Network 4(1) 2006.
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Carsten Mandt, Clinical Librarian, NHSGGC, West House, Audit Office, Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, G12 0XH. Phone: 0141-211 0633. E-mail: carsten.mandt@gartnavel.glacomen.scot.nhs.uk.