Adherence to the 2011 American Gastroenterological Association medical position statement for the diagnosis and management of Barrett's esophagus

Considerable variability exists in adherence to practice guidelines for Barrett's esophagus (BE). Rapid advances in management approaches to BE led to a new American Gastroenterological Association (AGA) medical position statement in 2011. Our aim was to assess how well members of the AGA Clinical Practice section adhered to these guidelines. A self‐administered survey incorporating questions on diagnostic criteria, cancer risk estimates, screening, surveillance, and therapeutics for BE was distributed electronically to 5850 North American members of the AGA Clinical Practice section. The response rate was 470 of 2040 opened e‐mails (23%). Intestinal metaplasia was required for diagnosis of BE by 90%, but the Prague classification was used by only 53% of those aware of it. The annual risk of progression to esophageal adenocarcinoma was reported as 0.1–0.5% by 76%. Screening practices were variable, with 35% screening all patients with chronic gastroesophageal reflux disease and 15% repeating endoscopy in patients with gastroesophageal reflux disease following a negative screening. Surveillance guidelines were followed by 79% for nondysplastic BE and 86% for low‐grade dysplasia, with expert pathology confirmation of dysplasia reported by 86%. Proton pump inhibitor dosing was variable, with 18% administering twice‐daily doses and 30% titrating dose to symptoms. Ablation therapy was recommended by 6% for nondysplastic BE, 38% for low‐grade dysplasia, and 52% for high‐grade dysplasia. There is satisfactory adherence to the new AGA guidelines with respect to diagnosis, cancer risk estimates, and surveillance intervals in a select group of respondents. However, adherence continues to be variable in the use of the Prague classification, screening, and dosing of antisecretory therapy. Use of ablation therapy increases with grade of dysplasia. The reason for continued variability in adherence to BE practice guidelines remains unclear, and more evidence‐based guidance is required to enhance clinical practice.     

Shared care for hearing complaints: guideline effects on patient flow

Rationale, aims and objectives A national guideline was proposed to enable shared care in hearing complaints and therefore to change patient flows. In this study the effect of this guideline is evaluated. Methods From a total of 3500 patients with hearing complaints, consulting the Ear Nose and Throat Department of a large non‐university hospital in the Netherlands in 2002, a random sample of 1000 patients was selected. Patient flow was simulated according to guideline criteria with as main outcome measures: the effect of the guideline on patient flow. Results Simulation of the consensus guideline did not really alter patient flow, with 89% to 97% of the patients still being referred to the Ear Nose and Throat specialist or Audiological Centre. Age, ear operations in the past and asymmetric hearing loss are the most important factors determining whether a person is labelled as a patient in need of medical care. Conclusion The present study emphasizes the importance of designing evidence‐based guidelines for shared care.     

Community-acquired pneumonia in the central desert and north-western tropics of Australia

Background: Community-acquired pneumonia (CAP) results in significant morbidity in central and north-western Australia. However, the nature, management and outcome of CAP are poorly documented. The aim of the study was to describe CAP in the Kimberley and Central Desert regions of Australia.
Methods: Prospective and retrospective cohort studies of inpatient management of adults with CAP at Alice Springs Hospital and six Kimberley hospitals were carried out. We documented demographic data, comorbidities, investigations, causes, CAP severity, outcome and concordance between prescribed and protocol-recommended antibiotics.
Results: Two hundred and ninety-three subjects were included. Aboriginal Australians were overrepresented (relative risk 8.1). Patients were notably younger (median age 44.5 years) and disease severity lower than in urban Australian settings. Two patients died within 30 days of admission compared with expected mortality based on Pneumonia Severity Index predictions of seven deaths (χ², P = 0.09). Disease severity and outcome did not differ between regions. Management differences were identified, including significantly more investigations, higher rates of critical care and broader antibiotic cover in Central Australia compared with the Kimberley. Sputum culture results showed Gram-negative organisms in both regions. However, Streptococcus pneumoniae was the most frequent organism isolated in the Kimberley and Haemophilus influenzae in Central Australia.
Conclusion: CAP in this setting is an Aboriginal health issue. The low mortality observed and results of microbiology investigations support the use of existing antibiotic protocols. Larger studies investigating CAP aetiology are warranted. Addressing social and environmental disadvantage remains the key factors in dealing with the burden of CAP in this setting.     

Clinical Imaging Guidelines Part 4: Challenges in Identifying,Engaging and Collaborating With Stakeholders

The effective development and use of clinical imaging guidelines requires an understanding of who the stakeholders are, what their interests in the process are, and what roles they should play. If the appropriate stakeholders are not engaged in the right roles, it is unlikely that clinical imaging guidelines will be successfully developed, relied on, and actually used. Some stakeholders are obvious: for the development of clinical imaging guidelines, both imagers and those who request examinations, such as general practitioners, internists, and medical specialists, must be involved. To gain acceptance, other relevant groups are stakeholders, including medical societies, other health care professionals, insurers, health IT experts and vendors, and patients. The role of stakeholders must be dictated by their specific interest. For some, involvement in the creation of guidelines is the right role. For others, such as regulators or insurers, reviews or invitations to comment are required, and for others, such as medical educators, it is probably sufficient to provide information and create awareness. Only through a careful consideration of who the stakeholders are and what are their interests are the successful development, acceptance, and use of clinical imaging guidelines likely to occur. Future efforts must focus on collaboration, particularly among groups that create clinical imaging guidelines and those that can support their use, and on regulatory roles and mandates.     

美国AHRQ《评估患者结局的注册登记指南(第2版)》解读

注册登记研究(registry study,RS)可反应真实世界医疗状况且适用范围广,在医学研究领域中应用越来越多,中医药研究领域也逐渐开展了多项大规模RS。RS属于观察性研究,与随机对照试验互相补充,尤其在小概率事件的研究中处于重要的地位。全球RS研究各具特点,质量参差不齐,为提高研究质量,美国卫生健康研究与质量管理署(agency for healthcare research and quality,AHRQ)于2010年发布了《评价患者结局注册登记指南(第2版)》(简称《指南(2)》),从RS的设计、实施到评估各个环节均做出了明确的定义及说明,并用38个研究范例将研究中可能遇到的问题进行了重点阐释,为RS的规范研究提供了可靠保障。"中药注射剂上市后安全性监测注册登记研究"是近年来在全国范围内开展的大型、多中心、高水平中医药安全性评价的RS,是《指南(2)》在中医药研究中应用的典型范例,全文结合该研究设计要点对《指南(2)》进行重点解读,为RS更好的在中国应用提供参考。     

A pan-Canadian practice guideline and algorithm: screening,assessment, and supportive care of adults with cancer-related fatigue

Purpose

The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults.

Methods

The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009.

Results

Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process.

Conclusions

Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.     

Lenalidomide in multiple myeloma—a practice guideline

Background

Promising new drugs such as lenalidomide, an immunomodulatory agent, are available for the treatment of multiple myeloma. We describe the process of creating a provincial guideline for the use of lenalidomide, alone or in combination with other drugs, in relapsed, refractory, or newly diagnosed disease (including smoldering and symptomatic patients, and candidates and non-candidates for transplant) and in maintenance treatment (after transplant or non-transplant therapy); and for strategies to manage lenalidomide-related toxicities.

Methods

Outcomes of interest included overall survival, event-free survival, progression-free survival, time to progression, time to next treatment, response rate, and incidence of serious toxicity. The medline, embase, and Cochrane Library databases, as well as meeting abstracts and the Web sites of relevant organizations, were systematically searched for relevant literature.

Results

Recommendations were developed using the evidence from published studies and the clinical expertise of the working group and of the Cancer Care Ontario Hematology Disease Site Group.

Conclusions

Lenalidomide in combination with dexamethasone can be recommended for both previously untreated and treated patients with multiple myeloma. Guidelines for the management of cytopenias, venous thromboembolism, and second primary malignancies are discussed.     

Eastern Canadian Colorectal Cancer Consensus Conference: standards of care for the treatment of patients with rectal,pancreatic, and gastrointestinal stromal tumours and pancreatic neuroendocrine tumours

The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Halifax, Nova Scotia, October 20–22, 2011. Health care professionals involved in the care of patients with colorectal cancer participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of rectal cancer, including pathology reporting, neoadjuvant systemic and radiation therapy, surgical techniques, and palliative care of rectal cancer patients. Other topics discussed include multidisciplinary cancer conferences, treatment of gastrointestinal stromal tumours and pancreatic neuroendocrine tumours, the use of folfirinox in pancreatic cancer, and treatment of stage ii colon cancer.     

Chinese Society of Gynecological Endocrinology affiliated to the International Society of Gynecological Endocrinology Guideline for Ovarian Tissue Cryopreservation and Transplantation

Abstract

In order to promote the standard application of ovarian tissue cryopreservation in China, and to provide effective scientific medical services of fertility preservation for patients, the First Chinese Guideline of Ovarian Tissue Cryopreservation and Transplantation is established according to the agreements between gynecologists, embryologists, oncologists, pediatricians, breast oncologists, hematologists, and experts on Traditional Chinese Medicine (TCM), based on already successful treated cases within Beijing Obstetrics and Gynecology Hospital, Capital Medical University, China, and based on already existing international guidelines on fertility preservation including important publications in this field. The guideline includes selection criteria, evaluation, and indications; SOPs of ovarian tissue removal, transportation, preparation, freezing, and thawing; approaches of ovarian tissue transplantation and follow-up; practical recommendations for ovarian tissue cryopreservation and transplantation including recommendations of the diseases where this method could be available, and treatment of menopausal symptoms during the peri-transplantation period (time between cryopreservation and retransplantation). The aim of this guideline was to be scientific, practical, and operable.