Do practice guidelines augment drug utilisation review?

Drug utilisation review (DUR) or drug use evaluation (DUE) studies or programmes are intended to detect and/or correct inappropriate drug use. Appropriateness can be assessed at 3 levels: (i) whether any medication is warranted, or whether either no therapy or nondrug therapy is preferred (level 1); (ii) assuming drug therapy is indicated, which of several alternative drugs is the preferred choice? (level 2); and (iii) appropriateness of the drug regimen, including dosage, duration, type and frequency of monitoring, and drug interactions (level 3). The traditional approach to DUR/DUE has been to begin the appropriateness evaluation after a drug is prescribed. However, changes in healthcare organisation provide the basis for a disease-management or health-maintenance approach to DUR/DUE, and practice guidelines afford a possible source for guiding such studies. We hypothesised that the latter approach to DUR/DUE would be more likely to result in evaluation of level 1 drug-therapy issues than the traditional DUR/DUE approach. We tested this hypothesis by reviewing 56 practice guidelines involving drug therapy and also reviewed research studies published from 1992 to 1996. We found that studies that used the traditional DUR/DUE approach were most likely to examine level 3 drug-therapy issues, never addressed level 1 issues, and typically evaluated adherence to provider- or study team-developed guidelines rather than published guidelines. In contrast, the disease- or health-management approach nearly always examined level 1 issues, seldom addressed level 3 issues, and almost always evaluated adherence to a published practice guideline. Regardless of the DUR/DUE approach, about 40% of studies evaluated level 2 issues. The guidelines themselves were much more likely to include recommendations about level 1 and level 2 issues than about level 3 issues; however, even when a guideline included level 2 or level 3 issues, studies of adherence to the guideline rarely assessed anything beyond level 1 issues. This suggests that guideline recommendations about level 2 and level 3 issues may be too imprecise for use in evaluative studies. The drug-information compendia, on the other hand, provide detailed recommendations about level 3 issues. Revision of drug compendia may be warranted to include recommendations about all levels of drug-therapy issues. The results of intervention studies to improve drug-therapy compliance with guidelines suggest that information provided at the time of prescribing, information presented by local health professionals and information provided with a large amount of provider contact may be more likely to demonstrate significant improvements in drug therapy. We conclude that practice guidelines are a useful resource for augmenting DUR/DUE but that challenges to optimising their use include whether they can be kept current, acceptable and accessible to providers.     

Clinical Analysis of 57 Patients with Ovarian Dysgerminoma

Objective  Ovarian dysgerminoma is an uncommon ovarian malignancy, Its clinicai features are special and there are many factors affecting its prognosis. If treated properly, the patient can be cured. Otherwise it may endanger the patient’s life. The aim of this study is to investigate the clinical features and factors related to prognosis of ovarian dysgerminoma. Methods  Data from 57 patients with pure ovarian dysgerminoma were analyzed retrospectively. The patients were admitted to the Cancer Center, Sun Yat-sen University from January 1.1964 to December 31, 2000. Results  The main clinical features were abdominal mass (56.1% ), abdominal pain (21.1% ), abdominal swelling (17.5%.), vaginal bleeding (5.3% )and genital tract abnormalities (5.3%). Twenty-six patients had stage I diseases, 8 stage II.9 stage III.1 stage IV and 13 recurrent and persistent diseases. The uterus was involved in 41.2% of patients with stage II -III diseases. Combined modality was given to 52 cases and a single-method treatment to 5 cases. The total overall 5 and 10-year survival rates for stages I-IV was 80.1 % and 70.0% respectively. The 5-year survival rate for stage I was 100%, stage II 55.2%. stage III 55.6% and stage IV 0%; for recurrent and persistent diseases, 72.7%. The stage I group of 12 patients. received adnexectomy and 14 patients underwent hysterectomy and adnexa removal. There was no significant difference between the 5 and 10-year survival rates (all 100%). Of the 23 patients in the stage I group to whom oniy chemotherapy was given after operation, 19 cases received 3 or more courses and were well without recurrence; 4 patients received only one course and one of them recurred 21 months after the operation. In the group of stages II and III cases, the 5-year survival rate was 86.7% for those whose chemotherapy courses were 3≥ 4 and 25.0% for patients who received less than 4 courses of chemotherapy (P<0.05). Conclusions  The prognosis of ovarian dysgerminoma is closely related to the disease stage and treatment modality. A fertility-preserving operation can be considered in early -staged patients, but caution needs to be exercised in the middle to late staged cases. Good results can be achieved with an operation-based combined modality in recurrent patients.     

Establishing and managing a periodontal biobank for research: the sharing of experience

Periodontal bio‐repositories, which allow banking of clinically validated human data and biological samples, provide an opportunity to derive biomarkers for periodontal diagnosis, prognosis and therapeutic activities which are expected to improve patient management. This article presents the establishing of the Malaysian Periodontal Database and Biobank System (MPDBS) which was initiated in 2011 with the aim to facilitate periodontal research. Partnerships were established with collaborating centres. Policies on specimen access, authorship and acknowledgement policies were agreed upon by all participating centres before the initiation of the periodontal biobank. Ethical approval for the collection of samples and data were obtained from institutional ethics review boards. A broad‐based approach for informed consent was used, which covered areas related to quality of life impacts, genetics and molecular aspects of periodontal disease. Sample collection and processing was performed using a standardized protocol. Biobanking resources such as equipment and freezers were shared with the Malaysian Oral Cancer Database and Tissue Bank System (MOCDTBS). In the development of the MPDBS, challenges that were previously faced by the MOCDTBS were considered. Future challenges in terms of ethical and legal issues will be faced when international collaborations necessitate the transportation of specimens across borders.     

Clinic-based ultrasound can predict malignancy in pediatric thyroid nodules

Background: Thyroid nodules in pediatric patients may carry a greater risk for malignancy than in adults. Most nodules >1?cm in patients ≤21 years of age may require thyroidectomy for definitive diagnosis and treatment. Although clinic-based ultrasound (CBUS) has been shown useful in the evaluation of thyroid nodules in adults, its utility in evaluating nodules in the pediatric population remains unclear. Methods: Prospectively collected data regarding 50 patients ≤21 years who underwent preoperative CBUS and initial thyroidectomy at a single institution were retrospectively reviewed. All CBUS were performed by endocrine surgeons certified in basic and cervical ultrasonography. Preoperative CBUS characteristics of pediatric thyroid nodules were analyzed with respect to final pathology. Results: Of the 50 patients ≤21 years of age who underwent surgical resection for a dominant thyroid nodule, there were 45 females and 5 males with an average age of 17.4 years (range: 10-21 years). On univariate analysis, microcalcifications (p<0.001), abnormal lymph nodes (p<0.001), and dimensions taller more than wide (p=0.033) were individual CBUS characteristics predictive of thyroid malignancy. All nine patients with abnormal lymph nodes on CBUS had malignant disease on final pathology. Multiple thyroid nodules, a cystic component, and echogenicity did not predict malignancy; regular borders trended toward predicting a benign nodule (p=0.066). When malignant ultrasound features were considered (i.e., hypoechoic, irregular borders, microcalcifications, abnormal lymph nodes, and shape taller more than wide), having one malignant feature predicted malignancy with an odds ratio of 2.0 while having ≥2 features held even greater significance (p=0.004, OR 4.0). All patients with ≥3 malignant ultrasound features had thyroid cancer on final pathology. Conclusion: CBUS is a useful diagnostic modality in determining malignancy status of thyroid nodules in patients ≤21 years of age. CBUS should be employed as part of an initial assessment of any pediatric patient presenting with thyroid nodules to help further guide management and treatment.     

Acute coronary syndromes

The first 150 words of the full text of this article appear below. Key points Coronary artery disease accounts for >30% ofdeaths in Western society. The diagnosis of myocardial infarctionshould be qualified by size, causation and time from occurrence. Mortalityis reduced by immediate or ‘primary’ percutaneouscoronary intervention or thrombolysis within the first 24 hof onset of ST-segment elevation myocardial infarction. Strategiesto reduce platelet activation (glycoprotein IIb/IIIa receptorantagonists, or clopidogrel) are now recommended in the treatmentof high-risk non-ST-segment myocardial infarction/unstable angina. Elevatedserum troponins may be the result of non-ischaemic myocardialdamage, especially in critical illness.