Guideline: "Treatment of acute perioperative and posttraumatic pain". Updating from the S2- to the S3-level: a preliminary report

The German guidelines for the treatment of acute perioperative and posttraumatic pain from 1999 have been revised during the last three years and will be published at the end of 2006 as a guideline on S3-level. 20 medical societies evaluate with the instruments of the centre of evidence based medicine of Oxford (CEBM) the available randomised controlled trials, systematic reviews and existing guidelines and consent in final Delphi rounds the detailed recommendations (grades A - C). Comprehensive information of the patients (pain level, therapeutic possibilities), measurement and documentation of pain, interdisciplinary management of therapy and complete consideration of all operative, pain therapeutic, medicinal, psychologic, physiotherapeutical and physical procedures are central aims of the actual guideline.     

European Association of Urology guidelines on Male Infertility: the 2012 update

CONTEXT: New data regarding the diagnosis and treatment of male infertility have emerged and led to an update of the European Association of Urology (EAU) guidelines for Male Infertility. OBJECTIVE: To review the new EAU guidelines for Male Infertility. EVIDENCE ACQUISITION: A comprehensive work-up of the literature obtained from Medline, the Cochrane Central Register of Systematic Reviews, and reference lists in publications and review articles was developed and screened by a group of urologists and andrologists appointed by the EAU Guidelines Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SUMMARY: These EAU guidelines are a short comprehensive overview of the updated guidelines of male infertility as recently published by the EAU (http://www.uroweb.org/guidelines/online-guidelines/), and they are also available in the National Guideline Clearinghouse (http://www.guideline.gov/).     

An updated overview of clinical guidelines for the management of non-specific low back pain in primary care

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.     

Haste makes waste—Should current guideline recommendations for initiation of renal replacement therapy for acute kidney injury be changed?

There is broad consensus among guideline organizations that renal replacement therapy (RRT ) should not be delayed in case of life‐threatening conditions. However, in case of severe acute kidney injury (AKI ) without these conditions, it is unclear whether immediate RRT has an advantage over delayed RRT . Two recently published randomized controlled trials (AKIKI and ELAIN ) with seemingly opposite results have reignited the discussion whether guideline recommendations on initiation strategies in severe AKI should be adapted. This editorial discusses RRT initiation strategies in severe AKI , based on recent literature and highlights the potential advantages and disadvantages of immediate vs delayed start. Overall, evidence in favor of immediate compared to delayed strategies is sparse and there is wide heterogeneity across studies making it difficult to draw firm conclusions. RRT should not be delayed in case of refractory hyperkalemia, severe metabolic acidosis or pulmonary edema resistant to diuretics. In all other cases, a delayed strategy seems justified and might enhance renal recovery. RRT is not a “it doesn't hurt to try” technique and can expose the patient to a higher risk of bleeding, hemodynamic problems, under‐dosing of antibiotics, loss of nutrients, catheter‐related complications and the uncertain effects of blood‐membrane interactions. There is no compelling reason to change current guideline recommendations and research focus should shift toward the development of algorithms as a decision aid tool for RRT initiation in severe AKI .     

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

Background contextThe North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.PURPOSEThe purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.Study designThis is a guideline summary review.MethodsThis guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.ResultsEighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.ConclusionsThe evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx     

Practical Use of the New American Urological Association Adult Urodynamics Guidelines

In 2012, the American Urological Association published guidelines on adult urodynamics. On the basis of a review of the available evidence, they established guideline recommendations for urodynamics in adults with stress urinary incontinence/pelvic organ prolapse, overactive bladder/urinary urgency incontinence/mixed urinary incontinence, neurogenic bladder, and lower urinary tract symptoms. This article reviews the practical use of these guidelines in a clinical practice.     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Background contextThe evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeProvide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsSixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

High-intensity focused ultrasound for prostate cancer: a practice guideline

Objective:

The aim of this practice guideline was to develop evidence-based recommendations for clinicians on the use of high-intensity focused ultrasound (HIFU) in patients with localized prostate cancer.

Methods:

The guideline was developed using the methods of Cancer Care Ontario’s Program in Evidence-Based Care (PEBC). The core methodology of the PEBC’s guideline development process is systematic review. A comprehensive literature search was undertaken to identify high-quality studies, reviews and other practice guidelines on the use of HIFU in prostate cancer. The evidence formed the basis of the recommendations, which were reviewed and amended where necessary, by clinical experts in medical and radiation oncology and urology.

Results:

The literature review yielded limited evidence. No randomized controlled trials or meta-analyses comparing HIFU with currently accepted management approaches were identified. The body of evidence is primarily based on data from case series. Internal feedback was provided by the PEBC Genitourinary Disease Site Group membership and the Report Approval Panel. External peer review included targeted review by clinical experts specifically requested to comment on the guideline, and professional consultation through an online survey of health care professionals.

Conclusion:

HIFU is currently not recommended as an alternative to accepted curative treatment approaches for localized prostate cancer.     

Contemporary diagnosis and management of squamous cell carcinoma (SCC) of the penis

What's known on the subject? and What does the study add? Penile cancer is a rare malignancy with limited evidence to support most treatment recommendations. No randomised controlled trials have been published and few recommendations are available for guiding management. However, evidence‐based guidelines are currently available through the European Association of Urology. This review provides the reader with the most up‐to‐date information on diagnosis and management of all stages of squamous cell carcinoma of the penis. It provides a rapid review and study guide for this rare disease.

• ? To review the current literature available on squamous cell carcinoma (SCC) of the penis and provide a contemporary management algorithm for treatment based on the best evidence available.
• ? A complete review of the current English language literature was performed via PubMed and all available guidelines were reviewed.
• ? Large randomised controlled trials are lacking in penile SCC due to the fortunately rare occurrence of the disease.
• ? Treatment recommendations for the primary lesion, lymph nodes, and follow‐up in this review are based on the best current available literature.
• ? Early diagnosis and aggressive organ‐sparing treatment remains the mainstay of therapy for penile SCC.
• ? Variable institutional expertise currently makes treatment decisions difficult and unstandardised.
• ? A multidisciplinary approach should be used in attempt to improve outcomes in this mutilating disease.

     

Surgical management of early stage invasive breast cancer: a practice guideline.

OBJECTIVES: To assess the available evidence on sentinel lymph-node biopsy, and to examine the long-term follow-up data from large randomized phase III trials comparing breast-conserving therapy with mastectomy in order to make recommendations on the surgical management of early invasive breast cancer (stages I and II), including the optimum management of the axillary nodes: for the breast--modified radical mastectomy or breast-conserving therapy; for the axilla--complete axillary node dissection, axillary dissection of levels I and II lymph nodes, sentinel lymph-node biopsy or no axillary node surgery. OUTCOMES: Overall survival, disease-free survival, local recurrence, distant recurrence and quality of life. EVIDENCE: MEDLINE, EMBASE, the Cochrane Library databases and relevant conference proceedings were searched to identify randomized trials and meta-analyses. Two members of the Practice Guidelines Initiative, Breast Cancer Disease Site Group (BCDSG) selected and reviewed studies that met the inclusion criteria. The systematic literature review was combined with a consensus process for interpretation of the evidence to develop evidence-based recommendations. This practice guideline has been reviewed and approved by the BCDSG, comprising surgeons, medical oncologists, radiation oncologists, pathologists, a medical sociologist, a nurse representative and a community representative. BENEFITS, HARMS AND COSTS: Breast-conserving therapy (lumpectomy with levels I and II axillary node dissection, plus radiotherapy) provides comparable overall and disease-free survival to modified radical mastectomy. Levels I and II axillary dissection accurately stages the axilla and minimizes the morbidity of axillary recurrence but is associated with lymphedema in approximately 20% of patients and arm pain in approximately 33%. Currently, there is insufficient data regarding locoregional recurrence and long-term morbidity associated with sentinel-node biopsy to advocate it as the standard of care. Breast-conserving therapy may offer an advantage over mastectomy in terms of body image, psychological and social adjustment but appears equivalent with regard to marital adjustment, global adjustment and fear of recurrence. RECOMMENDATIONS: Women who are eligible for breast-conserving surgery should be offered the choice of either breast-conserving therapy with axillary dissection or modified radical mastectomy. Removal and pathological examination of levels I and II axillary lymph nodes should be the standard practice in most cases of stages I and II breast carcinoma. There is promising but limited evidence to support recommendations regarding sentinel lymph-node biopsy alone. Patients should be encouraged to participate in clinical trials investigating this procedure. VALIDATION: A draft version of this practice guideline and a 21-item feedback questionnaire was circulated to 201 practitioners in Ontario. Of the 131 practitioners who returned the questionnaire, 98 (75%) completed the survey and indicated that the report was relevant to their clinical practice. Eighty (82%) of these practitioners agreed that the draft document should be approved as a practice guideline.     

Special Issue: KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.     

Making sense of the latest advice on vitamin D therapy

The Institute of Medicine recently published recommendations for the daily intake and optimal serum levels of vitamin D based on an extensive review of the existing literature. Here we examine the issue and put levels of vitamin D in context for the general population and in patients with chronic kidney disease. Large randomized controlled trials are necessary to ensure that current recommendations are appropriate.     

Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury

BACKGROUND/OBJECTIVES: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine METHODS: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. RESULTS: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. CONCLUSIONS: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.     

Minimally Invasive Management of Pancreatic Abscess, Pseudocyst, and Necrosis: A Systematic Review of Current Guidelines

BACKGROUND: Minimally invasive techniques have been used to manage infected pancreatic necrosis and its local complications, although there are no randomised trials to evaluate these techniques. The aims of this study were to review the scope and quality of recommendations in current clinical practice guidelines on the role of percutaneous catheter drainage and endoscopic techniques for pancreatic abscess, pseudocyst, and infected pancreatic necrosis and identify the degree of consensus between guidelines. METHODS: A MEDLINE search was performed to identify current guidelines from any professional body published in the English language. Guidelines were analysed to determine their specific recommendations for using percutaneous catheter drainage and endoscopic techniques to manage pancreatic abscess, infected pseudocyst, and infected pancreatic necrosis. RESULTS: Sixteen guidelines were reviewed. Percutaneous catheter drainage for pancreatic abscess was recommended by eight guidelines; for infected pseudocysts, one guideline did not recommend its use and six recommended its use; for infected necrosis, two guidelines did not recommend its use and four recommended its use. Endoscopic management of both pancreatic abscess and infected pseudocyst was recommended by seven guidelines; for infected necrosis, endoscopic management was recommended by ten guidelines. Ten guidelines did not include levels of evidence to support their recommendations. CONCLUSIONS: Guidelines lacked consensus in their recommendations for minimally invasive management of pancreatic abscess, infected pseudocyst, and infected necrosis, and few recommendations were graded according to the strength of the evidence. More prospective trials are needed to provide evidence where it is lacking, which should be incorporated into clinical practice guidelines.     

Pharmacologic treatment of male stress urinary incontinence: systematic review of the literature and levels of evidence

OBJECTIVE: Stress urinary incontinence (SUI) occurs in men and women. Pharmacologic treatment of female SUI has been beneficiary but the role of drug treatment in male SUI is controversial. This review evaluates the drug classes, the effects of these drugs in trials with male SUI, and the levels of evidence of the individual trials. METHODS: A systematic literature review was conducted searching for studies on male SUI published between 1966 and 2007. In retrieved articles, reference lists were hand-searched to identify additional articles. The level of evidence was judged according to the Oxford classification. RESULTS: This search found nine articles providing evidence that alpha-adrenoceptor agonists (ephedrine, phenylpropanolamine, midodrine), beta2-adrenoceptor agonists (clenbuterol), and serotonin-noradrenaline reuptake inhibitors (imipramine, duloxetine) have a potentially beneficial effect on male SUI. Most trials used only small numbers of patients and a mixed study population (men and women). The evidence level of most studies was low due to the lack of randomisation (case series or cohort studies, level 4). In contrast, the first high-level study to provide evidence in the treatment of male SUI was with duloxetine, a selective serotonin and noradrenaline reuptake inhibitor (randomised controlled study, level 1b). However, only one well-designed study has been published so far. CONCLUSIONS: One high-level study with duloxetine in combination with pelvic floor muscle training shows preliminary but promising results in the treatment of male SUI. These results have to be confirmed in larger and well-designed trials to allow definite recommendations for the pharmacologic treatment of male SUI.     

Therapeutic apheresis for renal disorders

This review summarizes the clinical evidence and practical details for the use of plasmapheresis and other apheresis modalities for each indication in nephrology. Updated information on the molecular biology and immunology of each renal disease is discussed in relation to the rationale for apheresis therapy and its place amid other available treatments. Autoantibody-mediated diseases, such as anti-GBM (anti-glomerular basement membrane) glomerulonephritis (GN), ANCA (antineutrophil cytoplasmic antibody)-related GN and the antibody-mediated type of TTP (thrombotic thrombocytopenic purpura), and alloantibody-mediated diseases such as kidney transplant sensitization and humoral rejection, can be treated by various plasmapheresis methods. These include standard plasmapheresis with a replacement volume, or plasmapheresis with online plasma purification using adsorption columns or secondary filtration. However, it should be noted that the pathogenic molecules implicated in FSGS (focal segmental glomerulosclerosis), myeloma cast nephropathy, and perhaps other diseases are too small to be removed by most online purification methods. A great majority of controlled trials and series on which evidence-based treatment recommendations are made were performed using centrifugal plasmapheresis; it is presumed that membrane-separation plasmapheresis is equally efficacious. For some rarer diseases, such as MPGN (membranoproliferative GN) type 2 with factor H abnormalities or C3Nef (C3 nephritic factor) autoantibodies, there are only a few case reports, but enough scientific understanding to warrant a trial of plasmapheresis in severe cases. Photopheresis, which is effective for cell-mediated rejection in heart and lung transplantation, has not yet found a place in the routine treatment of kidney transplant rejection.     

Gender-specific practice guidelines for coronary artery bypass surgery: perioperative management

Gender differences in coronary bypass surgery have been the focus of numerous publications in recent years. Unfortunately these publications have contradictions that leave surgeons with conflicting recommendations for care. To help resolve these inconsistencies, The Society of Thoracic Surgeons (STS) Workforce on Evidence-Based Surgery has carried out an objective review of published information in this field. The STS Workforce recognizes that there are important gender issues associated with referral bias, the impact of body size, psychosocial factors, and postoperative support, but the intent of this guideline is to focus specifically on perioperative management. As with all practice guidelines, our goal is to gather the most important information, analyze the information in a logical and unbiased fashion, and make recommendations based solely on the available evidence.