EULAR recommendations for knee and hip osteoarthritis: a critique of the methodology

The quality of the EULAR recommendations for the management of hip and knee osteoarthritis (OA) was evaluated using a validated instrument. The quality and methods were compared with other guidelines and recommendations. EULAR recommendations were found to be among the best for overall quality. They show strengths with respect to scope, rigour of development, and clarity, but weaknesses with respect to stakeholder involvement, applicability, and editorial independence. However, a principal strength is their attempt to fill the gap between guidelines based solely on either research evidence or expert opinion. The methods used to synthesise research evidence (systematic review) and expert opinion (Delphi exercise) are robust. Strength of recommendation, based on combined consideration of research evidence, clinical expertise, and perceived patient preference, is valid and approaches the true essence of “evidence based practice” that considers each of these different forms of evidence.     

The hospitalist

Efforts to improve the efficiency and quality of hospital inpatient care have led to the movement to replace the primary care physician with the hospitalist as the inpatient physician of record. A hospitalist serves as the physician of record after accepting referrals of hospitalized patients from primary care physicians. The hospitalist then keeps the primary care physician informed of major healthcare decisions during the patient's entire hospital stay. One of the forces promoting the hospitalist movement is the assumption that inpatient care provided by a small number of physicians is less costly, of higher quality, and less variable than the care provided by primary care physicians who see patients only briefly once a day. Hospitalists are accessible throughout their shifts and can better respond to changing patient needs. With this model of care, hospitalists have taken a more proactive role in redesigning support-care systems based on the needs of the patient. Many perform quality improvement and utilization review, and engage in the development of clinical practice guidelines. Concern over the hospitalist model has focused on the break in continuity of care. Patients and their families may feel that they are losing a physician whom they know and for whom they have some level of comfort and confidence. As the hospitalist movement picks up momentum, so too does its expectation to improve and provide for quality end of life care.     

American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy

PurposeTo provide updated American Brachytherapy Society (ABS) guidelines for transrectal ultrasound-guided transperineal interstitial permanent prostate brachytherapy (PPB).Methods and MaterialsThe ABS formed a committee of brachytherapists and researchers experienced in the clinical practice of PPB to formulate updated guidelines for this technique. Sources of input for these guidelines included prior published guidelines, clinical trials, published literature, and experience of the committee. The recommendations of the committee were reviewed and approved by the Board of Directors of the ABS.ResultsPatients with high probability of organ-confined disease or limited extraprostatic extension are considered appropriate candidates for PPB monotherapy. Low-risk patients may be treated with PPB alone without the need for supplemental external beam radiotherapy. High-risk patients should receive supplemental external beam radiotherapy if PPB is used. Intermediate-risk patients should be considered on an individual case basis. Intermediate-risk patients with favorable features may appropriately be treated with PPB monotherapy but results from confirmatory clinical trials are pending. Computed tomography–based postimplant dosimetry performed within 60 days of the implant is considered essential for maintenance of a satisfactory quality assurance program. Postimplant computed tomography–magnetic resonance image fusion is viewed as useful, but not mandatory.ConclusionsUpdated guidelines for patient selection, workup, treatment, postimplant dosimetry, and followup are provided. These recommendations are intended to be advisory in nature with the ultimate responsibility for the care of the patients resting with the treating physicians.     

A re-look at an old disease: a multimodality review on gout

Gout, the most common form of microcrystalline arthropathy has always interested radiologists. The diagnosis of gout is primarily based on clinical and laboratory findings; however, it has well known and characteristic radiographic manifestations. Radiographs remain the examination of choice in the diagnosis of joint involvement. Plain radiographs are less sensitive to early changes in gout than other imaging techniques. Recently, magnetic resonance imaging (MRI), ultrasound (US), and computed tomography (CT) have demonstrated an increasing role in early diagnosis of gouty arthritis, for assessing the extent of soft-tissue involvement and as problem-solving tools for diagnostically difficult cases. Cross-sectional imaging can also be used for guiding needle aspirations in patients with an acute attack of gout, which may simulate an infective process clinically. This pictorial review illustrates the main imaging features of gout on radiographs, MRI, CT, and ultrasound with the aim of helping the radiologist to make a confident diagnosis in radiographically typical cases and to serve as a problem-solving tool in cases that present a diagnostic dilemma.     

Tophaceous gout in an amputation stump in a patient with chronic myelogenous leukemia

Gout is a common rheumatologic disorder that can have an unusual clinical presentation. This case report describes the development of a gouty tophus at a site of remote traumatic forearm amputation in a patient with chronic myelogenous leukemia (CML). It further addresses the imaging characteristics of tophaceous gout as well as the differential diagnostic considerations as regards both the imaging findings and the clinical presentation.     

Chest X-ray ordering related to varied clinical scenarios: a survey of Saskatchewan physicians.

INTRODUCTION: The chest X-ray (CXR) is one of the most commonly requested diagnostic imaging examinations. It is estimated that over 250,000 CXRs are ordered in Saskatchewan annually. Judicious use of the CXR is valuable in patient care, while unnecessary use increases costs, adds to patient irradiation, and may be in conflict with standards of patient care. In 1993, the Saskatchewan Health Services Utilization and Research Commission (HSURC) developed clinical practice guidelines (CPGs) for the CXR. These guidelines were based on a metaanalysis of validated literature. We were uncertain about whether Saskatchewan physicians were ordering CXRs based on the HSURC CXR CPGs. MATERIALS AND METHODS: A survey, based on recommendations from the HSURC CXR CPGs, was developed and distributed to 363 physicians in Saskatchewan by mail (30/363) and by email (333/363). The survey asked physicians if they would order, or not order, a CXR for 5 basic clinical scenarios. The question of whether to order a CXR was then repeated when the basic scenario was altered one variable at a time, to determine if the physicians would change their CXR orders. RESULTS: According to our assessment of physician responses to the initial clinical scenarios, the surveyed physicians correctly followed the HSURC CXR CPGs in the following frequencies: 100% scenario 1, 91.9% scenario 2, 35.4% scenario 3, 100% scenario 4, and 61.2% scenario 5. Alteration of the basic clinical scenarios resulted in very unpredictable ordering of CXRs by the survey participants. CONCLUSION: The Saskatchewan physicians we surveyed are not ordering CXRs on the basis of HSURC CXR CPGs. They order too many nonindicated CXRs. Further communication with, and education of, the physician population about the HSRUC CXR CPGs may be warranted.     

肌骨超声在痛风诊疗中的应用与研究进展

痛风是由长期高尿酸血症（HUA）导致单钠尿酸盐（MSU）晶体在关节和其他组织中异常沉积所引起的代谢性疾病。超声可早期发现MSU晶体在关节周围沉积,从无症状高尿酸血症（AH）期到痛风晚期均有特异性超声表现,而且超声可对痛风累及范围和程度进行随访监测。综述痛风的超声影像学特点并对超声在降尿酸治疗监测和痛风治疗中的研究进展加以介绍。     

Elements of a stroke center

The past decade has ushered in a refined understanding of--and commitment to--objective evidence-based practice of stroke management. Responding to the need for universal protocol-driven guidelines for stroke care, the Brain Attack Coalition published consensus statements with recommendations for primary stroke centers (Alberts MJ, et al, JAMA 283:3102-3109, 2000) and comprehensive stroke centers (Alberts MJ, et al, Stroke 36:1597-1616, 2005) in 2000 and 2005, respectively. These benchmark publications helped to define a new "standard of care" for stroke patients and laid the groundwork to establish formal certification for stroke centers. Although large randomized controlled trials evaluating the efficacy of these guidelines are currently underway, several recent reports suggest that stroke center certification may improve outcomes in patients with acute ischemic stroke. In this article, the authors briefly discuss the status of stroke center certification and the evolution of stroke systems of care.     

Factors affecting patient compliance in the acute setting: an analysis of 20,000 imaging reports

The aim of this study was to identify the risk factors associated with noncompliance of recommendations made by emergency radiologists. Between March 2012 and August 2012, our team retrospectively reviewed 20,000 consecutive emergency department (ED) patients receiving imaging to assess how often emergency radiologists made recommendations, how often they were followed, and what factors were associated with noncompliance. Faculty (Radiology or Emergency Medicine) were considered senior if they had been practicing for >5 years post residency/fellowship training. Faculty practicing <5 years were considered junior physicians. The following data was extracted from the electronic medical records and the hospital information system: recommendation in imaging report, age, gender, race (Caucasian, African-American, and others), insurance status, primary care contact, distance from the hospital to patient residence, and primary language. Recommendations were categorized as follows: (1) immediate follow-up, (2) follow-up 1–4 weeks, (3) follow-up 1–3 months, (4) follow-up 4–6 months, (5) follow-up 7–12 months, and (6) clinical/laboratory follow-up recommendations irrespective of time. We identified 1,650 recommendations (1,650/20,000?=?8.25 %). Using a one-to-one logistic regression analysis, the following factors were significant (P?<?0.05) when evaluating noncompliance: increasing age, no primary care physician, lack of insurance, primary language other than English, increased distance from hospital, and extended follow-up interval. Noncompliance with recommended additional imaging (RAI) is multifactorial. Primary and/or referring physicians should take notice of the aforementioned compliance trends and mitigating factors, adopt systematic safety measures and create interdepartmental dialogue with radiology to ensure compliance, and counsel and educate patients about the importance of imaging recommendations.     

痛风影像学诊断方法分析及发展

痛风是由于尿酸盐沉积产生的异质代谢性疾病,严重者可导致关节残疾引起肾功能损伤,但若能早期诊断该病或可逆转.众所周知,痛风不同时期有不同的临床表现和影像学表现.一般而言,在痛风早期,其双轨征特征明显,特异性高,适合采用超声法进行检测;在痛风反复发作期及慢性期,适合采用X线平片、CT和MRI等影像技术进行检测,其中MRI能...     

The Practice Guidelines for Primary Care of Acute Abdomen 2015

Background

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines [all clinical questions (CQs) and recommendations are shown in supplementary information].

Methods

A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen.

Results

A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended.

Conclusions

The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

     

2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI)

Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.     

Imaging Evidence and Recommendations for Traumatic Brain Injury: Conventional Neuroimaging Techniques

Imaging plays an essential role in identifying intracranial injury in patients with traumatic brain injury (TBI). The goals of imaging include (1) detecting injuries that may require immediate surgical or procedural intervention, (2) detecting injuries that may benefit from early medical therapy or vigilant neurologic supervision, and (3) determining the prognosis of patients to tailor rehabilitative therapy or help with family counseling and discharge planning. In this article, the authors perform a review of the evidence on the utility of various imaging techniques in patients presenting with TBI to provide guidance for evidence-based, clinical imaging protocols. The intent of this article is to suggest practical imaging recommendations for patients presenting with TBI across different practice settings and to simultaneously provide the rationale and background evidence supporting their use. These recommendations should ultimately assist referring physicians faced with the task of ordering appropriate imaging tests in particular patients with TBI for whom they are providing care. These recommendations should also help radiologists advise their clinical colleagues on appropriate imaging utilization for patients with TBI.     

A rare cause of spinal cord compression: imaging appearances of gout of the cervical spine

Gout is a metabolic disorder typically affecting the peripheral joints, more commonly in males. Spinal involvement is uncommon and is usually associated with hyperuricemia. We present the imaging findings of a case of spinal gout in a female patient with no previous history of hyperuricaemia, involving multiple spinal segments.     

Quality assessment in primary military clinics of the Israel Defense Forces Northern Command

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.     

原发性痛风危险因素的研究

 目的 探讨原发性痛风的危险因素。方法 病例-对照研究1996年1月～2000年1月专科门诊132名新患者,资料处理采用条件Logistic回归分析。结果 原发痛风的独立危险因素：职业、外向性格、饮酒、高嘌呤膳食、高血压及家族史、冠心病及家族史、目前收缩压和舒张压、体质指数(BMI)、尿酸清除分数、急性痛风关节炎发作部位的外伤史、痛风家族史、甘油脂(TG)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL)、极低密度脂蛋白胆固醇(VLDL)的升高及高密度脂蛋白胆固醇2(HDL2C)的降低。结论 国人对于原发痛风的危险因素应早期预防。     

Practice guidelines: the radiology perspective

Clinical practice guidelines have emerged as a reality for medical practitioners over the past 20 years. Although virtually all groups interested in the development of practice guidelines hope for improvements in patient care, secondary expectations vary widely among those using them. Their use in daily practice by physicians has met with resistance from barriers including concerns of “cookbook” medicine, a loss of autonomy, and increased professional liability. The recent experience of the ACR in addressing these challenges illustrates that physicians are receptive to steps perceived to mitigate the risks accompanying the use of guidelines as well as to efforts to increase their understanding of implementing guidelines in clinical practice. The experiences of other medical societies and an inventory of future trends reveal additional challenges associated with the use of practice guidelines, as third parties look to guidelines as points of reference for gauging the performance of health care providers.     

原发性痛风临床特点及危险因素分析

 目的 了解原发性痛风的临床特点,分析与其相关的高危因素,为临床诊断以及预防痛风提供参考.方法 回顾性分析195例初诊的原发性痛风患者的一般情况、生活方式、临床资料,以及实验室检查结果,并对原发性痛风发生的危险因素进行分析.结果 195例中,男性占97.4％ (190/195),发病高峰在40～60岁(54.9％,107/195).最常见的首发部位为第一跖趾关节,占86.2％ (168/195).单因素Logistic同归分析显示:(1)原发性痛风的发生与高嘌呤饮食相关,与吸烟、饮酒无关,若患者生活中既饮酒又吸烟,痛风发生的危险性将明显增高;(2)高体质指数(body mass index,BMI)、高血压、高血压家族史、冠心病家族史为原发性痛风的高危因素;(3)血脂组中:除载脂蛋白A(Apo -A)外,其余指标均与原发性痛风相关.三酰甘油(TG)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、载脂蛋白B(Apo -B)浓度的升高,高密度脂蛋白胆固醇(HDL - C)浓度的降低为痛风发病的高危因素.血清尿酸清除分数( FEuA)降低是痛风发生的独立危险因素.结论 中老年男性原发性痛风的发病率较高,原发性痛风的危险因素包括:高嘌呤饮食,饮酒合并吸烟,高BMI、高血压、高血压家族史、冠心病家族史,高血脂等.中国人存在多种原发痛风的危险因素,应早期预防.     

Pulmonary rehabilitation: an underutilized resource in primary COPD care

Pulmonary rehabilitation (PR) is an important component of chronic obstructive pulmonary disease (COPD) management. Physician use of PR for patients with COPD lags behind national and international guideline recommendations. In this article, we discuss the important components of PR, including exercise training, self-management education, and psychosocial and nutritional interventions, as based on the American Thoracic Society/European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We also discuss the potential benefits of PR, including reduction of respiratory symptoms, decreased disability, and increased participation in physical and social activities. Increased activity promotes independence, improves quality of life, and reduces the number of COPD exacerbations and hospitalizations. In all stages of COPD, PR has been shown to result in improved exercise tolerance, with reduced dyspnea and fatigue, although the greatest improvement has been seen in patients with GOLD stages II to IV. Pulmonary rehabilitation is now a well-recognized therapy that should be available to all patients with symptomatic COPD. To facilitate inclusion of PR in COPD management, primary care physicians need to recognize and diagnose COPD, and regularly decide when PR best fits in an individual's COPD treatment program.     

Similarities and differences in follicular cell-derived thyroid cancer management guidelines used in Europe and the United States

The management of thyroid cancer has become more refined and complex over the last thirty years. In an effort to provide guidance to both clinicians and patients, several organizations have developed clinical management guidelines that provide specific advice regarding the diagnosis, treatment and follow-up of differentiated thyroid cancer. In this review, we compare and contrast the major management recommendations provided in the guidelines of the European Thyroid Association with those published by thyroid cancer specialty organizations in the United States (American Thyroid Association and National Comprehensive Cancer Network). By carefully examining treatment and management approaches that are applied in other areas of the world, we can identify equally effective alternative treatment or follow-up options that may find applicability to specific patients in our own practice. Despite significant difference in cultures, economies, and health care delivery systems, thyroid cancer management recommendations from the European experts and the American experts are far more similar than they are different. Each of the guidelines strongly endorses an initial management approach that is guided by individualized estimates of risk of recurrence and risk of death. Furthermore, follow up and additional therapeutic recommendations are based on revised risk estimates that reflect an individual patient's response to therapy.