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PubMed1996

Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment.

PURPOSE: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence. PATIENTS AND METHODS: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients. RESULTS: Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7). CONCLUSIONS: These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Accidental Falls↗

PubMed2001

[French and foreign recommendations for the practice of anesthesia-intensive care].

UNLABELLED: This article reviews the development of STANDARDS, Recommendations and Guidelines for practice in anaesthesiology in France and other countries. The French society for anaesthesia and intensive care (Sfar) has published, since 1989, 11 basic STANDARDS: 1) Recommendations for the monitoring of patients during anaesthesia (June 1989, amended on January 1994) [APSF Newsletter, Summer 1990, page 22]; 2) Recommendations for postanaesthesia monitoring and care (September 1990); 3) Recommendations for preanaesthesia care (September 1991); 4) Recommendations for anaesthetic apparatus and checking before use (January 1994); 5) Recommendations for the equipment of anaesthesia working places (January 1995); 6) Recommendations for the tasks of the nurse anaesthetist (January 1995); 7) Recommendations for hygiene standards in anaesthesia practice (December 1997); 8) Recommendations for outpatient anaesthesia (September 1990); 9) Recommendations for the practice of obstetrical analgesia (September 1992); 10) Recommendations for interhospital physician-accompanied transfers (December 1992); 11) Recommendations for intrahospital physician-accompanied transfers (February 1994). Additionally the Sfar produced or coproduced 9 Experts' conferences, 15 Consensus conferences and 5 Guidelines for clinical practice.

Anesthesia↗

PubMed2002

Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography.

PURPOSE: To examine how frequently Breast Imaging Reporting and Data System (BI-RADS) mammographic screening assessments were associated with expected clinical management recommendations. MATERIALS AND METHODS: Seven Breast Cancer Surveillance Consortium mammography registries recorded screening assessments and recommendations in 1997 to identify the proportion of women in each BI-RADS category. The first screening assessment for a woman without cancer or a prior mammogram within 9 months was associated with its independently recorded recommendation. RESULTS: Among 292,795 women, screening assessments included 269,022 (91.9%) with a "negative" or "benign finding," and 267,103 (99.3%) of these women were recommended for normal interval follow-up. Among 11,861 (4.1%) women with screening assessments of "probably benign finding," 4,782 (40.3%) were recommended for short interval follow-up as expected on the basis of the BI-RADS, but a high proportion (36.9%) were recommended for additional imaging. Among 1,625 (0.6%) women with "suspicious abnormality," most were recommended for biopsy (48.7%) or clinical examination and/or surgical consult (9.0%), but many were recommended for additional imaging (38.7%). Among 243 (0.1%) women with screening assessments "highly suggestive of malignancy," a majority were recommended for biopsy (73.3%) or clinical examination and/or surgical consult (18.1%) consistent with BI-RADS, but some were recommended for additional imaging (6.6%). CONCLUSION: BI-RADS assessments and management recommendations are consistent for negative and benign assessments, but inconsistencies were found in assessments and recommendations for mammographic abnormalities.

Adult↗

PubMed2005

Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up.

PURPOSE: To compare cancer yield for screening examinations with recommendation for short-interval follow-up after diagnostic imaging work-up versus after screening mammography only. MATERIALS AND METHODS: From January 1996 to December 1999, Breast Imaging Reporting and Data System assessments and recommendations were collected prospectively for 1,171,792 screening examinations in 758,015 women aged 40-89 years at seven mammography registries in Breast Cancer Surveillance Consortium. Registries obtained waiver of signed consent or collected signed consent in accordance with institutional review boards at each location. Diagnosis of invasive cancer or ductal carcinoma in situ within 24 months of screening examination and tumor stage and size for invasive cancer were determined through linkage to pathology database or tumor registry. chi2 test was used to determine significant differences between groups. RESULTS: Overall, 5.2% of first and 1.7% of subsequent screens included recommendation for short-interval follow-up, which was similar to likelihood of recommendation for diagnostic evaluation (first screens, 4.6%; subsequent, 2.6%). Most recommendations for short-interval follow-up were based on screening mammography alone (86.2% of first screens, 77.5% of subsequent). Yield of cancer for screening examinations with probably benign finding (PBF) and recommendation for short-interval follow-up based on screening mammography alone tended to be lower than in those with PBF and recommendation for short-interval follow-up after additional work-up (first screens: 0.54% vs 0.96%, P=.10; subsequent: 1.50% vs 1.73%, P=.26). Proportion of stage II and higher disease tended to be higher for examinations with PBF and recommendation for short-interval follow-up based on screening mammography alone compared with those recommended for short-interval follow-up after additional work-up (first screens: 34.7% vs 24.4%, P=.43; subsequent: 27.5% vs 19.2%, P=.13). CONCLUSION: Many first screening examinations include recommendation for short-interval follow-up based on screening mammography alone. Cancer yield for these examinations is low and is lower than that with diagnostic work-up prior to short-interval follow-up recommendation. Absence of diagnostic work-up prior to short-interval follow-up recommendation may result in periodic surveillance of a high proportion of benign lesions.

Adult↗

PubMed2005

Managing febrile infants: impact of literature recommendations published during a physician's residency.

The authors hypothesized that sepsis workup recommendations are associated with practice recommendations published during the physician's residency. The first published recommendations suggesting sepsis workups for nontoxic, young, febrile infants appeared in pediatric journals from 1975-1980 and in family practice journals from 1981-1987. Data are from the Community Tracking Study (3,272 pediatricians and 2,432 family physicians). "Percentage of sepsis workups recommended" was defined by response to a vignette about the percentage of well-appearing 6-week-old children with a fever of 101 degrees F for whom the physician would recommend a sepsis workup. Multivariable regression with piecewise linear functions evaluated workup recommendations by timing of literature recommendations during residency. Pediatricians recommended sepsis workups 81.6% of the time and family physicians 67.7% (p < .001). Increased recommendations occurred among pediatricians who completed residency from 1975-1980 (p < .05) and among family physicians who completed residency from 1981-1987 (p < .005), when specialty-specific journals published recommendations for sepsis workups for febrile infants. The association between publication of sepsis workup recommendations during a physician's residency and increased sepsis workup recommendations suggests an unrecognized and enduring impact of such publications.

Diagnostic Tests, Routine↗

PubMed2002

Lack of control of high blood pressure and treatment recommendations in Canada.

BACKGROUND: Hypertension is a major risk factor for death that affects many Canadians, but only 16% of hypertensive Canadians are treated and have their hypertension controlled. While the control rate is very low, the 2001 Canadian Hypertension Recommendations do not recommend that low risk hypertensive patients be started on pharmacotherapy, and pharmacotherapy is not recommended for people for whom there is no demonstrable benefit from randomized, controlled trails. OBJECTIVES: To determine the proportion of hypertensive patients who are appropriately managed according to the 2001 Canadian Hypertension Recommendations. METHODS: Data from the Canadian Heart Health Survey, which surveyed a cross-sectional population (n=23,129) between 1986 and 1992, were used to determine the proportion of nondiabetic hypertensive patients who are managed according to the 2001 Canadian Hypertension Recommendations. Hypertensive patients not recommended to receive pharmacotherapy include those without risk factors and target organ damage, with a diastolic blood pressure of 90 to 99 mmHg and a systolic blood pressure of less than 160 mmHg. People with diastolic blood pressures of less than 90 mmHg who have systolic blood pressures of 140 to 159 mmHg are also not recommended to have pharmacotherapy. Patients prescribed antihypertensive therapy who had blood pressure controlled to less than 140/90 mmHg were assessed as having their hypertension managed appropriately, as were those who were not treated and were not recommended to be prescribed treatment. RESULTS: There were 58,813 (1.7%) hypertensive patients who did not have target organ damage or additional risk factors, and had a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure between 90 and 99 mmHg. Twenty four per cent of hypertensive persons (831,787) had a systolic blood pressure of 140 to 160 mmHg and a diastolic blood pressure of less than 90 mmHg. About 25% (23.6%+1.7%) of hypertensive Canadians in the Canadian Heart Health Survey are not recommended to be prescribed antihypertensive therapy according to the 2001 Canadian Hypertension Recommendations. Sixteen per cent of hypertensive patients were treated and had their blood pressures controlled (blood pressure less than 140/90 mmHg). Therefore, about 41% (ie, 16%+25%) of hypertensive patients are appropriately managed according to the 2001 Canadian Hypertension Recommendations. CONCLUSIONS: The results of the Canadian Heart Health survey indicate that there are a striking number of Canadians with untreated high blood pressure (59%) who probably do not have their hypertension managed according to the 2001 Canadian Hypertension Recommendations. Greater efforts are required to identify people with hypertension, and to ensure that they are managed according to the best available evidence.

Adolescent↗

PubMed1988

Family practice physicians' perceptions of the usefulness of drug therapy recommendations from clinical pharmacists.

Family practice physicians' perceptions of the usefulness and clinical outcome of drug therapy recommendations made by clinical pharmacists in a family medicine clinic were determined. For 15 weeks, pharmacists in the clinic recorded all consultations in which they made recommendations about the drug therapy of specific patients. At the time of each consultation, the pharmacists gave the physician a questionnaire designed to gauge the physician's opinion of the usefulness of the consultation. Physicians who implemented the recommendations were sent a second questionnaire and asked to indicate the extent to which the clinical pharmacist influenced their decision to implement the recommendation, the effect the recommendation had on the patient's clinical status, and the usefulness of the recommendation to the patient in ways unrelated to clinical status (such as greater patient acceptance, safety, or lower cost). Five clinical pharmacists provided 59 consultations to 33 physicians. The physicians rated 51 (88%) of the consultations as very useful, and they implemented 78 (98%) of the 80 recommended actions. Of the 56 physicians who attributed their decision to implement the recommendation to their consultation with the clinical pharmacist, 43 believed that the recommendations had improved the clinical status of the patient, and 38 believed that the recommendations were useful to patients in ways unrelated to clinical status. Physicians in a family medicine residency training program had positive perceptions of the usefulness of drug therapy recommendations made by clinical pharmacists. A majority of the physicians believed that the recommendations had a positive effect on patients' clinical status.

Attitude of Health Personnel↗

PubMed2002

The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy.

OBJECTIVE: To provide updated, evidence-based recommendations for the therapy of hypertension in adults. OPTIONS: For patients with hypertension, a number of antihypertensive agents may control blood pressure. Randomized trials evaluating first-line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed. OUTCOMES: The health outcomes that were considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence. EVIDENCE: MEDLINE was searched for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension. Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other published studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and mortality. BENEFITS, HARMS AND COSTS: Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood-pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality. RECOMMENDATIONS: The present document contains detailed recommendations pertaining to treatment thresholds, target blood pressures, and choice of agents in various settings in patients with hypertension. The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus, the amalgamation of the previous sections on treatment of hypertension in the young and old into one section, increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke. Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk, the presence and/or absence of target organ damage, and comorbidities. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving high levels of consensus are reported here. These guidelines will continue to be updated annually.

Antihypertensive Agents↗

PubMed1999

Users' guides to the medical literature: XVI. How to use a treatment recommendation. Evidence-Based Medicine Working Group and the Cochrane Applicability Methods Working Group.

Clinicians can often find treatment recommendations in traditional narrative reviews and the discussion sections of original articles and meta-analyses. Making a treatment recommendation involves framing a question, identifying management options and outcomes, collecting and summarizing evidence, and applying value judgments or preferences to arrive at an optimal course of action. Each step in this process can be conducted systematically (thus protecting against bias) or unsystematically (leaving the process open to bias). Clinicians faced with a plethora of recommendations may wish to attend to those that are less likely to be biased. Therefore, we propose a hierarchy of rigor of recommendations to guide clinicians when judging the usefulness of particular recommendations. Recommendations with the highest rigor consider all relevant options and outcomes, include a comprehensive collection of the methodologically highest quality data with an explicit strategy for summarizing the data (that is, a systematic review), and make an explicit statement of the values or preferences involved in moving from evidence to action. High rigor recommendations come from systematically developed, evidence-based practice guidelines or rigorously conducted decision analyses. Systematic reviews, which typically do not consider all relevant options and outcomes or make the preferences underlying recommendations explicit, offer intermediate rigor recommendations. Traditional approaches in which the collection and assessment of evidence remains unsystematic, all relevant options and outcomes may not be considered, and values remain implicit, provide recommendations of weak rigor. In an era in which clinicians are barraged by recommendations as to how to manage their patients, this hierarchy provides a potentially useful set of guides.

Decision Making↗

PubMedDate not supplied

Compliance with the recommendations of medical consultants.

Compliance with the consultant's recommendations is one measure of the effectiveness of a consultation. A previous study showed that compliance was better when fewer recommendations were made. In the subsequent year, consultants were encouraged to limit their recommendations to five or fewer. Despite a significant decrease in the number of recommendations, compliance rates remained essentially unchanged (72%). Multivariate analysis demonstrated that the clinical severity of the patient's disease and the number of associated problems, as well as the types of recommendations, were significant predictors of compliance. Compliance was best for recommendations involving medications (84%) and worst for recommendations involving diagnostic tests (62%). Compliance was also evaluated in the context of a surgeon's view of the appropriateness of the recommendations. For recommendations felt to be essential to patient care the compliance rate was 75%, but it was only 44% for recommendations judged nonessential (p less than 0.001). The consulting internist should be aware that the surgeon's view of the relevance of the recommendations to patient care needs may have an important effect on compliance.

Analysis of Variance↗

PubMed2002

Attributes of clinical recommendations that influence change in practice following audit and feedback.

The object of this study was to determine which attributes of clinical practice recommendations influence changes in clinical practice following audit and feedback. This was an observational study using multilevel modeling to examine the relationship between attributes of clinical practice recommendations and compliance with the recommendations before and after audit and feedback. Sixteen hospital gynecology units in Scotland participated in a national audit project. Clinical practice recommendations covering selected gynecological topics were developed and data collected to assess baseline (preintervention) compliance. Summaries of performance were fed back to consultant gynecologists in each hospital and follow-up (postintervention) data were collected. Trained audit assistants used standardized forms to abstract data from case notes. Compliance data were available at baseline and follow-up for a total of 42 clinical practice recommendations. Altogether, 4,664 case notes contributed to baseline data and 4,382 to follow-up data. Thirteen attributes describing clinical practice recommendations were developed, based upon previous work, and pretested. A panel of seven consultant gynecologists rated the extent to which each of the 42 recommendations possessed each of the 13 attributes. The main outcome measures were the association of each attribute with compliance and with changes in clinical practice. Recommendations compatible with clinician values and not requiring changes to fixed routines were independently associated with greater compliance at baseline and follow-up. However, recommendations incompatible with clinician values were independently associated with greater change in practice following audit and feedback. Attributes of recommendations may influence the effectiveness of audit and feedback in secondary care. Recommendations seen as incompatible with clinician values are associated with lower compliance but greater behavioral change following audit and feedback.

Attitude of Health Personnel↗

PubMed1998

Implications of the traditional and the new ACSM physical activity recommendations on weight reduction in dietary treated obese subjects.

OBJECTIVE: To assess the acceptance of the traditional American College of Sports Medicine (ACSM) exercise recommendation (20-60 min of vigorous exercise at least three times per week) and of the new, broader Centers for Disease Control (CDC)/ACSM physical activity recommendation (30 min of moderate intensity activities on most days of the week) in an obese population and to elucidate the implications of meeting these recommendations on weight reduction during dietary treatment. DESIGN: Prospective dietary intervention study of 1000 kcal diet daily. SUBJECTS: 109 obese subjects (age: 45.6 +/- 13.1 y, body mass index (BMI): 38.1 +/- 6.0 kg/m2, (Female/Male: 81/19%) MEASUREMENTS: The time spent in moderate (3-6 MET, metabolic equivalents) and vigorous (6-10 MET) physical activities was assessed by use of the Stanford-7-Day-Physical-Activity-Recall-Questionnaire, with subsequent allocation of the subjects to one of three physical activity groups: meeting the traditional recommendation (TR), the new recommendation (NR) or neither of both (SED, sedentary subjects). Physical activity level, physical activity energy expenditure, total energy expenditure (based upon the questionnaire) and resting metabolic rate (by standard equation) were estimated at baseline. Body weight was determined at baseline and after a mean of 16.3 weeks of dietary treatment. RESULTS: The new, broader recommendation was met by twice as many of the obese subjects (34%) as was the traditional recommendation (17%). Weight reduction at follow up (-8.2 +/- 6.5 kg, 16.3 +/- 4.3 weeks, mean +/- s.d.) was positively correlated with the physical activity level at baseline (r = 0.49, P < 0.001). Meeting either the traditional or the new recommendation was associated with greater weight loss [-11.9 +/- 8.5 kg (TR) and -10.1 +/- 6.4 kg (NR), respectively, not statistically significant (NS)] as compared to being sedentary [-6.5 +/- 5.2 kg (SED), P < 0.05 vs both NR and TR]. CONCLUSIONS: Not only participation in vigorous exercise, but also regular engagement in moderate intensity physical activities, as recently recommended by the CDC/ACSM, predicts greater weight reduction during dietary treatment, compared to being sedentary. The new, broader physical activity recommendation appears to be more readily accepted by obese subjects than the former ACSM recommendation on exercise training.

Adult↗

PubMed1997

Prevention of bacterial endocarditis: recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

Anti-Bacterial Agents↗

PubMed1997

Prevention of bacterial endocarditis. Recommendations by the American Heart Association.

American Heart Association↗

PubMed1993

Agreement among dentists' recommendations for restorative treatment.

Differences among dentists in their decisions to recommend treatment have been studied principally at a "macro" level by examinations of variations in dentists' treatment recommendations for individual patients, or for patients aggregated to the practice level. If reasons for these differences are to be understood, however, a "micro" level examination of differences in dentists' decisions to recommend treatment for individual teeth is necessary. Extent of agreement to recommend treatment among dentists was explored for 1187 teeth in 43 patients. Each tooth was examined by a mean of 6.6 general practitioners. A modified reliability index and distributions of raw levels of agreement were used for quantification of agreement rates across an incomplete cross-classification for practitioners and patients. Overall inter-dentist reliability in recommending individual teeth for treatment was moderate, p = 0.62. Among unrestored teeth with no clinically evident caries, as judged by an independent experienced evident caries, as judged by an independent experienced examiner, reliability in treatment recommendations due to caries was fair, p = 0.51. Reliability was lowest for recommendations concerning previously restored teeth, p = 0.43. Among all teeth receiving at least one recommendation for treatment, only 22% received a unanimous recommendation. Over one-half of all instances of lack of agreement resulted from a single dentist's recommendation differing from those of all other dentists examining the tooth. The results suggest that much of the variation in dentists' practice profiles is due to basic differences in decisions to recommend treatment for individual teeth with specific conditions, and that the presence of previous restorations seems to magnify these differences.

Adult↗

PubMed2001

New recommendations from the 1999 American College of Cardiology/American Heart Association acute myocardial infarction guidelines.

OBJECTIVE: To review literature relating to significant changes in drug therapy recommendations in the 1999 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for treating patients with acute myocardial infarction (AMI). DATA SOURCES: 1999 ACC/AHA AMI guidelines, English-language clinical trials, reviews, and editorials researching the role of drug therapy and primary angioplasty for AMI that were referenced in the guidelines were included. Additional data published in 2000 or unpublished were also included if relevant to interpretation of the guidelines. STUDY SELECTION: The articles selected influence AMI treatment recommendations. DATA SYNTHESIS: Many clinicians and health systems use the ACC/AHA AMI guidelines to develop treatment plans for AMI patients. This review highlights important changes in AMI drug therapy recommendations by reviewing the results of recent clinical trials. Insights into evolving drug therapy strategies that may impact future guideline development are also described. CONCLUSIONS: Several changes in drug therapy recommendations were included in the 1999 AMI ACC/AHA guidelines. There is emphasis on administering fibrin-specific thrombolytics secondary to enhanced efficacy. Selection between fibrin-specific agents is unclear at this time. Low response rates to thrombolytics have been noted in the elderly, women, patients with heart failure, and those showing left bundle-branch block on the electrocardiogram. These patient groups should be targeted for improved utilization programs. The use of glycoprotein (GP) IIb/IIIa receptor inhibitors in non-ST-segment elevation MI was emphasized. Small trials combining reduced doses of thrombolytics with GP IIb/IIIa receptor inhibitors have shown promise by increasing reperfusion rates without increasing bleeding risk, but firm conclusions cannot be made until the results of larger trials are known. Primary percutaneous coronary intervention (PCI) trials suggest lower mortality rates for primary PCI when compared with thrombolysis alone. However, primary PCI, including coronary angioplasty, is only available at approximately 13% of US hospitals, making thrombolysis the preferred strategy for most patients. Clopidogrel has supplanted ticlopidine as the recommended antiplatelet agent for patients with aspirin allergy or intolerance following reports of a better safety profile. The recommended dose of unfractionated heparin is lower than previously recommended, necessitating a separate nomogram for patients with acute coronary syndromes. Routine use of warfarin, either alone or in combination with aspirin, is not supported by clinical trials; however, warfarin remains a choice for antithrombotic therapy in patients intolerant to aspirin. Beta-adrenergic receptor blockers continue to be recommended, and emphasis is placed on improving rates of early administration (during hospitalization), even in patients with moderate left ventricular dysfunction. New recommendations for drug treatment of post-AMI patients with low high-density lipoprotein cholesterol and/or elevated triglycerides are included, with either niacin or gemfibrozil recommended as an option. Supplementary antioxidants are not recommended for either primary or secondary prevention of AMI, with new data demonstrating lack of efficacy vitamin E in primary prevention. Estrogen replacement therapy or hormonal replacement therapy should not be initiated solely for prevention of cardiovascular disease, but can be continued in cardiovascular patients already taking long-term therapy for other reasons. Bupropion has been added as a new treatment option for smoking cessation. As drug therapy continues to evolve in treating AMI, more frequent updates of therapy guidelines will be necessary.

Adrenergic beta-Antagonists↗

PubMed2005

Health food stores' recommendations for nausea and migraines during pregnancy.

BACKGROUND: Many pregnant women use dietary supplements during pregnancy; however, relatively scant information is available on the safety of these products. Consumers of dietary supplements often rely on employees of health food stores to provide recommendations. OBJECTIVE: To evaluate recommendations made by health food store employees in the Phoenix metropolitan area regarding treatment of nausea/vomiting and migraines during pregnancy. METHODS: Phone calls were made by a disguised shopper to 155 health food stores in the greater Phoenix area. The caller posed as a woman 8 weeks' pregnant asking for recommendations for treatment of nausea/vomiting and migraines. Responses and recommendations were recorded and then compared with current scientific evidence obtained during a search of the literature using MEDLINE (1966-September 2004) as to whether or not the supplements and the methods of their use during pregnancy were contraindicated. RESULTS: Eighty-nine percent of stores offered recommendations for nausea/vomiting, and 82% provided recommendations for migraines. The use of ginger was the most recommended therapy for nausea/vomiting. Only 3.6% of respondents recommended correct usage, but failed to supply the correct dosage and duration. A total of 15 of 278 (5%) recommendations, for both nausea/vomiting and migraines, were for products contraindicated in pregnancy. CONCLUSIONS: In light of the increased use of dietary supplements by women during pregnancy, the willingness of personnel in health food stores to make any recommendations should foster concerns by patients and healthcare providers alike. Use of dietary supplements contraindicated in pregnancy could cause significant harm to the mother and/or fetus. Studies are needed to address the need for more stringent guidelines regarding health food stores and their recommendations.

Data Collection↗

PubMed1997

Food intakes of US children and adolescents compared with recommendations.

OBJECTIVES: To determine the proportion of youth meeting national recommendations for food group intake and to identify food intake patterns. DESIGN: The US Department of Agriculture's 1989-1991 Continuing Surveys of Food Intakes by Individuals were used to estimate food intake. Intake was determined from 3 days of diet by disaggregating foods into their component ingredients and using weights that correspond to servings. PARTICIPANTS: The sample included 3307 youth, 2 to 19 years of age, living in the 48 conterminous United States. Main Outcome Measures. Mean number of servings and percentage of individuals meeting national recommendations for food group intake according to demographic characteristics, patterns of intake, and nutrient profiles associated with each pattern. RESULTS: Mean numbers of servings per day were below minimum recommendations for all food groups except the dairy group (ages 2 to 11). Percentages of youth meeting recommendations ranged from approximately 30% for fruit, grain, meat, and dairy to 36% for vegetables. Sixteen percent of youth did not meet any recommendations, and 1% met all recommendations. The pattern of meeting all recommendations resulted in nutrient intakes above the recommended dietary allowances and was high in fat. Conversely, meeting none of the recommendations resulted in intakes well below the recommended dietary allowances for some nutrients. Total fat and added sugars averaged 35% and 15% of energy, respectively, and levels were similar among most demographic groups. CONCLUSION: Children and teens in the United States follow eating patterns that do not meet national recommendations. Nutrition education and intervention are needed among US children.

Adolescent↗