Clinical practice guidelines

Transferring results of research into clinical practice and their effective use for decisions in health care have become a major concern and are pivotal to quality improvement. Among the tools that have been developed are clinical practice guidelines (CPG). Developing reliable and valid recommendations requires a rigorous methodological approach that combines a systematic review of the results of clinical research with expert, pondered and explicit judgment. Guaranteeing applicability and implementation of these recommendations implies asking the question of how acceptable the recommendations are for the patient, the availability of the procedure and the expertise necessary in the specific context as well as identification of the organizational impact when put into action. CPG are a source of information not only for physicians but also for policy makers, insurance institutions, continued education programs and production of information for high quality decision making for patients.     

Clinical guidelines for nocturia

Nocturia is a bothersome condition, defined as a complaint whereby the individual has to wake one or more times per night in order to void. Nocturia that occurs twice or more per night can have a substantial adverse effect on the patient's quality of life (QOL), and in many cases treatment may be required. These guidelines provide a treatment algorithm for use by primary care physicians. The initial assessment is conducted through a history taking interview. With a clear understanding of symptoms, patients can be classified into three broad categories: (1) nocturia only, (2) nocturia and diurnal pollakisuria without other lower urinary tract symptoms, and (3) nocturia and diurnal pollakisuria accompanying other lower urinary tract symptoms. For treatment, the literature supporting each form of drug therapy was ranked and a recommendation grade was determined for each form of therapy. A grade of ‘F (pending)’ was applied to any drug not currently approved for use in Japan or for which the efficacy and safety in Japanese patients was unconfirmed at the time of evaluation. We recommend instruction and guidance on water intake that will generally result in 24‐h urine volume of 20 to 25 mL/kg. This corresponds to a daily water intake of 2.0% to 2.5% of body weight. In Japan, desmopressin is indicated for central diabetes insipidus and nocturnal enuresis, but not indicated for nocturia. The therapeutic mechanism of the anticholinergic drugs for nocturia may depend on the action of the sensory nerve mediated by the muscarinic receptors.     

Clinical practice guidelines and guideline development

Multiple health care agencies have called for the increased use of clinical practice guidelines to improve health care quality. Evidence-based clinical practice guidelines are those developed with the least bias. The process of developing guidelines through the American Academy of Orthopedic Surgeons is reviewed. The advantages and disadvantages of guidelines, as well as their limitations are presented. Guidelines can have a positive impact on patient care, improve physician education, and direct future clinical research.     

Clinical guidelines on central venous catheterisation

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence‐Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow‐up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide‐bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long‐term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long‐term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator‐assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow‐up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.     

机器人肝胆胰手术操作指南

<正>微创化是肝胆胰外科发展的趋势,机器人手术系统以其先进的技术优势,为肝胆胰手术的微创化操作带来了诸多改变。目前,我国机器人肝胆胰手术尚处于起步阶段。为推动机器人肝胆胰手术的规范发展,保障医疗质量和安全,原国家卫生和计划生育委员会医疗管理服务指导中心组织国内部分肝胆     

Clinical guidelines for idiopathic normal pressure hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) is a syndrome characterized by gait disturbance, dementia, and/or urinary incontinence without causative disorders, and ventricular enlargement due to disturbance of the cerebrospinal fluid (SF) circulation. The number of patients with iNPH will increase with the aging of the population in Japan. However, iNPH is often difficult to differentiate from other senile disorders such as lumbar canal stenosis, parkinsonism, and so on. Clinical guidelines for iNPH are required to improve understanding and provide for patients' quality of life and social care. These guidelines propose three levels of iNPH: possible, probable, and definite. Possible iNPH includes one or more of the classical triad and ventricular dilation in middle aged and elderly patients with closing of the CSF space at high convexity on magnetic resonance imaging. Probable iNPH shows improvement of the symptoms after CSF removal in patients with possible iNPH. Definite iNPH shows clinical improvement after CSF shunt operation. The CSF tap test is a major diagnostic measure because of the simplicity and less invasiveness. Use of the programmable valve is recommended to decrease CSF overdrainage. These guidelines are helpful for the diagnosis and treatment of iNPH.     

Clinical practice guidelines to inform evidence-based clinical practice

Background  

With the volume of medical research currently published, any one practitioner cannot independently review the literature to determine best evidence-based medical care. Additionally, non-specialists usually do not have the experience to know best practice for all of the frequent clinical circumstances for which there is no good evidence. Clinical practice guidelines (CPGs) help clinicians to address these problems because they are systematically created documents that summarize knowledge and provide guidance to assist in delivering high-quality medicine. They aim to improve health care by identifying evidence that supports the best clinical care and making clear which practices appear to be ineffective.     

Clinical guidelines for interstitial cystitis/bladder pain syndrome

The clinical guidelines for interstitial cystitis and related symptomatic conditions were revised by updating our previous guidelines. The current guidelines define interstitial cystitis/bladder pain syndrome as a condition with chronic pelvic pain, pressure or discomfort perceived to be related to the urinary bladder accompanied by other urinary symptoms, such as persistent urge to void or urinary frequency in the absence of confusable diseases. The characteristic symptom complex is collectively referred as hypersensitive bladder symptoms. Interstitial cystitis/bladder pain syndrome is divided into Hunner-type interstitial cystitis and bladder pain syndrome; Hunner-type interstitial cystitis and bladder pain syndrome represent interstitial cystitis/bladder pain syndrome with Hunner lesions and interstitial cystitis/bladder pain syndrome without Hunner lesions, respectively. So-called non-Hunner-type interstitial cystitis featured by glomerulations or bladder bleeding after distension is included in bladder pain syndrome. The symptoms are virtually indistinguishable between Hunner-type interstitial cystitis and bladder pain syndrome; however, Hunner-type interstitial cystitis and bladder pain syndrome should be considered as a separate entity of disorder. Histopathology totally differs between Hunner-type interstitial cystitis and bladder pain syndrome; Hunner-type interstitial cystitis is associated with severe inflammation of the urinary bladder accompanied by lymphoplasmacytic infiltration and urothelial denudation, whereas bladder pain syndrome shows little pathological changes in the bladder. Pathophysiology would also differ between Hunner-type interstitial cystitis and bladder pain syndrome, involving interaction of multiple factors, such as inflammation, autoimmunity, infection, exogenous substances, urothelial dysfunction, neural hyperactivity and extrabladder disorders. The patients should be treated differently based on the diagnosis of Hunner-type interstitial cystitis or bladder pain syndrome, which requires cystoscopy to determine the presence or absence Hunner lesions. Clinical studies are to be designed to analyze outcomes separately for Hunner-type interstitial cystitis and bladder pain syndrome.     

Clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome

A clinical guideline and algorism for interstitial cystitis and hypersensitive bladder syndrome has been developed by a group of East Asian urologists as a revised form of the Japanese guideline for interstitial cystitis. The guideline defines interstitial cystitis (IC) as a disease of the urinary bladder diagnosed by 3 requirements; 1) a characteristic complex of lower urinary tract symptoms, 2) bladder pathology such as Hunner's ulcer and bladder bleeding after overdistension, and 3) exclusions of confusable diseases. The characteristic symptom complex is termed as hypersensitive bladder syndrome (HBS), which is defined as bladder hypersensitivity, usually associated with urinary frequency, with or without bladder pain. For the definite diagnosis of IC, cytoscopy or hydrodistension is crutial; HBS is the diagnosis when IC is suspected but not confirmed by the 3 requirements. Numerous therapeutic options are available; however, most of them lack in high level of evidence, leaving a few as recommended therapies. Etiology of IC are multifactorial; the interaction among nervous, immune and endocrine factors forms a vicious cycle, provocating and maintaining inflammatory reactions in the bladder. The inclusion and efficacy criteria for clinical trials should be standardized to enhance the clinical research for this disabling disease, which has proved to be more prevalent than previously believed.     

中国非特异性腰背痛临床诊疗指南

腰背痛(low back pain,LBP)是骨科常见疾病,其中非特异性腰背痛(nonspecific low back pain,NSLBP)占90％左右,严重影响患者的生活质量.鉴于NSLBP诊疗理念和技术手段的不断进步,有必要制定符合中国临床实际的NSLBP诊疗标准. 近5年来,国内和国际上发表了多篇有关LBP的...