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PubMed1991

Team acceptance of specific recommendations for the treatment of VPI as provided by speech pathologists.

This retrospective study describes the frequency of one team's acceptance of speech pathologists' recommendations for specific secondary treatment procedures for the correction of VPI for 100 consecutive patients. In addition, assessment was made of the level of success in eliminating VPI relative to treatments utilized that were recommended by speech pathologists versus level of success when treatment other than that recommended by speech pathologists were used. For the 78 patients who received the treatment procedure recommended by speech pathologists, only 10 percent continued to demonstrate any clinically significant residual speech problem associated with VPI. However, for the 22 patients who received treatment other than that which had been recommended, 32 percent continued to demonstrate clinically significant speech problems associated with VPI. Data is presented on the success rate for correcting VPI relative to specific treatment recommendations including pharyngeal flap, palatal pushback, pharyngeal wall implant, tonsillectomy, prosthetic palatal lifts, and speech therapy.

Clinical Protocols↗
PubMed1994

[Validity of the values of maximal oxygen intake for women recommended in the 'Quantity of exercise for developing health' by Ministry of Health and Welfare].

The purpose of this study was to examine the value of maximal oxygen intake per kilogram body weight (VO2max/wt) recommended for women between 20 and 29 years of age by the Ministry of Public Welfare. The subjects were 199 female college students, who were not in the habit of drinking and smoking. Results obtained were as follows: After controlling the effects of age and percent body fat (%fat), VO2max/wt showed a significant correlations with %fat, high-density lipoprotein cholesterol and systolic blood pressure. The values of VO2max/wt corresponding to borderline values of these CHD risk factors ranged from 27.6 to 29.5ml/kg.min. The highest value of VO2max/wt was very close to the value recommended for women older than 60 years of age by the Ministry of Public Welfare. The subjects were then divided into 4 groups; at above and below the value of VO2max/wt (35ml/kg.min) recommended for women between 20 and 29 years of age, and at above and below the value of VO2max/wt (31ml/kg.min) recommended for women older than 60 years of age by the Ministry of Public Welfare. There were no significant differences among 4 groups in occurrence of abnormal values in CHD risk factors. The results of this study support the validity of the value of VO2max/wt (31ml/kg.min) recommended for women older than 60 years of age by the Ministry of Public Welfare. However, it seems that it is not necessary to recommend the value of VO2max/wt (35ml/kg.min) for women between 20 and 29 years of age, who were not in the habit of drinking and smoking.

Adult↗
PubMed2006

Prescribing antiepileptics for the elderly: differences between guideline recommendations and clinical practice.

The incidence of epilepsy in patients aged >60 years is higher than in any other period of life. Yet, until recently, what was known about the treatment of older patients with epilepsy has been inferred from studies in younger patients. A growing body of clinical evidence focused exclusively on the elderly suggests that, while some issues are similar for older and younger adults, older patients with epilepsy may require even more attention regarding antiepileptic drug (AED) selection than younger patients. This article reviews published guidelines and recommendations to identify explicit recommendations for use of specific AEDs in the elderly, and assesses the extent to which those recommendations have been adopted in clinical practice. We found that while one systematically derived guideline stated that lamotrigine may be a good choice for older patients because of its favourable adverse effect profile, only clinical recommendations based on expert opinion explicitly identified AEDs that are more and less appropriate for use in the elderly. Examination of published studies describing recent AED-prescribing patterns suggests that clinical recommendations have been, at best, slowly adopted. This observation is exemplified by the fact that older patients newly diagnosed with epilepsy are still prescribed phenobarbital--a drug identified as suboptimal in 1985. In order to better understand the delay in adopting clinical recommendations, we examine these findings in light of diffusion of innovations theory, a theory that has been used to understand dissemination of other new medical technologies. According to this theory, while it is too early to suggest that use of second-generation AEDs in the elderly has been delayed, the continued use of phenobarbital in older patients newly diagnosed with epilepsy represents a serious delay in adoption of recent guidelines. Delays may be related to lack of knowledge by primary care clinicians and emergency room physicians (who frequently treat older patients with epilepsy), lack of 'opinion leaders' in primary care and perhaps general neurology, clinicians' focus on seizure control as the primary endpoint in treating patients with epilepsy, and difficulties in changing long-standing prescribing patterns. Research targeting barriers to more appropriate prescribing is needed to determine appropriate strategies for changing AED prescribing practices in the elderly.

Aged↗
PubMedDate not supplied

Are psychiatric consultants' recommendations followed?

The extent of adherence to psychiatric consultants' recommendations was calculated through a review of charts. All charts of patients seen in Psychiatric consultation from May 1976 to April 1977 were reviewed and a total of 273 charts contained scoreable consultant recommendations. Recommendations were scored as either actively followed, passively followed or not followed. Results are reported for the extent of adherence 1) between different types of recommendations (medications, disposition, etc.), 2) between medical, surgical and obstetrical-gynecological services and 3) between consultants, two psychiatrists and one psychologist. The results suggest that recommendations more likely to be followed are those easily performed by a consultee and leading to direct, tangible results. Adherence to consultants' recommendations is discussed in the context of resistance to psychiatric consultation.

Hospital Departments↗
PubMed2002

Use of the American College of Radiology BI-RADS guidelines by community radiologists: concordance of assessments and recommendations assigned to screening mammograms.

OBJECTIVE: This study evaluated the use of the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) by community radiologists by determining the concordance of assessment categories and recommendations assigned to screening mammograms. MATERIALS AND METHODS: The study comprised the interpretations of 82,620 consecutive screening mammograms by 18 radiologists between January 1, 1995, and December 31, 1998. For all mammograms, assessment categories and recommendations were compared to determine whether they were in accordance with BI-RADS guidelines. Overall patterns of discordance were analyzed, and comparisons of discordant patterns by assessment category, patient age, breast density, and year of examination were made. RESULTS: The overall discordance between BI-RADS assessments and recommendations was low (3%). The assessment with the highest discordance was "probably benign finding" (category 3), at 53.5%. Mammograms obtained in 1998 were almost half as likely to have assessment-recommendation discordance compared with those obtained in 1995 (2.4% vs 4.5%, respectively; odds ratio = 0.52; p < 0.001). Mammograms of women with dense breast tissue were 30% more likely to have lesions assigned discordant assessments and recommendations compared with those of women with fatty tissue (3.4% vs 2.7%, respectively; odds ratio = 1.3; p < 0.001). No differences in the patterns of discordance were found between mammograms of women younger than 50 years and those of women 50 years old and older (p = 0.10). CONCLUSION: There has been improvement in the accurate application of BI-RADS since its introduction. However, variation in the pairing of BI-RADS assessments and recommendations persists. Continued efforts to educate radiologists about the use of BI-RADS and to clarify BI-RADS terms would promote maximum consistency in this use of this reporting method.

Adult↗
PubMed1993

Are current pediatric dose recommendations for intravenous theophylline appropriate?

Theophylline, a first-line antiasthma drug, is often associated with severe toxicity even when taken in the recommended schedule. Theophylline toxicity has been associated with upper respiratory tract infections (URTI) due to reduced total-body clearance of theophylline. Some researchers believe this inhibition stems from a direct effect of viruses, but others postulate it is a result of the fever. We examined whether current theophylline dose recommendations are appropriate for children with acute asthma with a concurrent URTI. We also wished to elucidate whether the viral infection or the fever inhibits theophylline clearance. A total of 2254 medical records of asthmatic children admitted to The Hospital for Sick Children in Toronto were reviewed between 1987 and 1990. Clearance rate was calculated as the ratio between the infused dose rate and measured steady-state concentrations. Subsequently, these clearance rates were used to calculate steady-state concentrations that would be achieved by the recommended dose rates of theophylline. Reduced theophylline clearance was associated with the presence of URTI (p = 0.029) but not fever. Age correlated significantly with theophylline clearance (p = 0.027). If these children were to receive the recommended intravenous dose rate of theophylline, two-thirds of them would achieve steady-state serum concentrations above 15 mg/L, and one-third would achieve concentrations above 20 mg/L. Reevaluation of the present recommended theophylline dose rate is needed, as the majority of children requiring intravenous theophylline have a concurrent URTI with compromised total-body clearance. A correction factor of 60% is recommended to adjust the dose rate during an URTI. If utilized by prescribing physicians, it may reduce theophylline toxicity during an URTI episode.

Adolescent↗
PubMed2006

Haloperidol dose when used as active comparator in randomized controlled trials with atypical antipsychotics in schizophrenia: comparison with officially recommended doses.

OBJECTIVE: To determine the doses of haloperidol as a comparator drug in randomized controlled trials (RCTs) with atypical antipsychotics in patients with schizophrenia and to compare these doses with the officially recommended doses for haloperidol in the United States and the United Kingdom. DATA SOURCES: We searched for RCTs conducted and published in English in full before January 2005 in which atypical antipsychotics were compared with haloperidol for the treatment of schizophrenia. We searched for Cochrane Reviews in which 1 of the following atypical antipsychotics was evaluated for the treatment of patients with schizophrenia, schizophreniform psychosis, or other primary psychosis: amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, sertindole, and ziprasidone. For the gap between the end point of inclusion of the studies in the Cochrane Reviews and January 2005, we electronically searched the Cochrane Central Register of Controlled Trials for any further RCTs in which atypical antipsychotics were compared with haloperidol for the same indication. Search terms used were haloperidol and schizophren and haloperidol and psychotic, as well as the names of the selected atypical antipsychotics for the years that were not covered by the Cochrane Reviews. For each study, the required dose and mean dose of haloperidol were compared with officially recommended doses of haloperidol in U.S. (Food and Drug Administration) and U.K. (British National Formulary) guidelines. DATA SYNTHESIS: In all of the included studies (N = 49), the midpoints of the required doses were above the midpoint of the official recommended doses in the United States and United Kingdom for moderately ill patients. In 94% (U.S.) and 80% (U.K.) of the studies, they were above the upper border of the recommended doses. Compared with recommended doses for severely ill patients in both the United Kingdom and United States (range, 6-15 mg daily), in 17 studies (35%) the mean actual used dose was above the upper dose border for severely ill patients (15 mg daily). CONCLUSIONS: Nearly all randomized clinical trials used haloperidol in doses that were higher than the official recommended doses for moderately ill or even severely ill patients. Therefore, it is probable that the results of the RCTs were affected by the high dose of haloperidol, hampering the interpretation of the effects of atypical anti-psychotics in their comparison with haloperidol.

Antipsychotic Agents↗
PubMedDate not supplied

Adherence to occupational therapist recommendations for home modifications for falls prevention.

OBJECTIVE: This study examined adherence to home modification recommendations made by an occupational therapist and attempted to identify predictors of adherence. METHOD: An experienced occupational therapist visited the homes of 178 people (mean age = 764 years) to evaluate for and recommend appropriate home modifications for falls prevention. One year later, a research assistant visited these persons' homes to assess adherence. RESULTS: At least one home modification was recommended in 150 of the 178 homes visited. The most common recommendations were to remove mats and throw rugs (48%), to change footwear (24%), and to use a nonslip bathmat (21%). In the 121 homes revisited after 12 months, 419 home modifications had been recommended, and 216 (52%) were met with partial or complete adherence. The only significant predictors of adherence were a belief that home modifications can prevent falls and having help at home from relatives. CONCLUSION: A major barrier to adherence to home modification recommendations is that many older people do not believe that home modifications can reduce their risk of falling.

Accidental Falls↗
PubMed2000

College of American Pathologists Conference XXXV: solid tumor prognostic factors-which, how and so what? Summary document and recommendations for implementation. Cancer Committee and Conference Participants.

The College of American Pathologists convened a prognostic factor conference in June 1999 to consider prognostic and predictive factors in breast, colon, and prostate cancer, and to stratify these factors into categories reflecting the strength of published evidence. Because so little progress in prognostic factor clinical utility has been made in the last 5 years, the conference participants focused their attention on decreasing variation in methods, interpretation, and reporting of these factors so that greater clarity of value could be achieved. The conference was organized to promote discussion, broad input, and future planning. An initial plenary session provided an overview of the status of tumor marker research, the impact of variation in medicine and pathology, and statistical issues related to prognostic factor research. In working group sessions for each cancer type, participants interactively evaluated and refined the documents created by the expert panels. A second plenary session dealt with issues common to all 3 groups, including the problem of micrometastases in lymph nodes in these sites; statistical issues that arose during the breakout discussions; and issues of variation in methods, interpretation, and reporting of immunohistochemical assays. A faculty session brainstormed strategies that could be used to implement the changes recommended. This session included invited representatives of the Food and Drug Administration, Health Care Financing Administration, Centers for Disease Control and Prevention, National Cancer Institute, American Joint Committee on Cancer, and International Union Against Cancer. Cancer site and general recommendations were presented and discussed during a final session to achieve consensus of the conference participants and to address feasibility of implementation of these recommendations. A final discussion focused on future initiatives that might lead to implementation of the changes proposed in the conference by the various organizations represented. This report summarizes the general conference recommendations, cancer working group recommendations, and plans for implementation of the recommendations.

Biometry↗
PubMed2003

Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.

BACKGROUND: The management of patients with acute nonvariceal upper gastrointestinal bleeding has evolved substantially over the past 10 years amid a paucity of published consensus guidelines. PURPOSE: To provide evidence-based management recommendations that address clinically relevant issues. REVIEW AND CONSENSUS PROCESSES: A multidisciplinary consensus group of 25 voting participants representing 11 national societies used a 7-step approach to develop recommendation statements according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. The quality of the evidence, the strength of the recommendation, and the level of consensus were graded according to recognized classifications. MAIN FINDINGS: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. The placement of endoscopic clips for endoscopic hemostasis appears promising. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding should be tested for Helicobacter pylori infection and receive eradication therapy if infection is present. FUTURE DIRECTIONS: The efficacy of newer endoscopic therapeutic technologies, the optimal regimen of proton-pump inhibition, and the roles of other pharmacologic agents require further research.

Endoscopy, Gastrointestinal↗
PubMed2004

Screening for family and intimate partner violence: recommendation statement.

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for family and intimate partner violence, based on the USPSTF's examination of evidence specific to family and intimate partner violence, and updates the 1996 recommendations on this topic. In 1996, the USPSTF found insufficient evidence to recommend for or against the use of specific instruments to detect domestic violence (a grade C recommendation, according to 1996 grade definitions). The USPSTF now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria from those in 1996. The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on the USPSTF Web site (http://www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (http://www.guideline.gov). The USPSTF recommendation, the accompanying summary article, and the complete systematic evidence review are available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov). The summary article and the USPSTF recommendation statement are available in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).

Adult↗
PubMed1999

[Standards, options and recommendations (SOR) for diagnosis, treatment and follow-up of osteosarcoma. Groupe de travail SOR].

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. For pediatric issues, this project is a collaboration between the FNCLCC and the French Society of Pediatric Oncology (SFOP). The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommendations for the clinical care of osteosarcoma in children and adult. METHODS: Data have been identified by literature search using Medline (1985-december 1998) and the expert groups personal reference lists. The main criteria considered were incidence, risk factors, prognostic factors and efficacy of treatment. Once the guidelines were defined, the document was submitted for review to 27 national and international independent reviewers, and to the medical committees of the 20 French Cancer Centres and, in particular, the 4 which have particular expertise in pediatric cancer management. RESULTS: The main recommendations for osteosarcoma management are that: 1) the clinical diagnosis is based on appropriate clinical and radiological findings; 2) the final diagnosis is pathological and the biopsy should be performed by the surgeon who will subsequently perform the definitive surgery; 3) surgical biopsy must be of adequate size and performed by an experienced surgeon; 4) the therapeutic strategy for osteosarcoma is based on surgery with neoadjuvant and adjuvant chemotherapy given in experienced centres. Inclusion of high dose methotrexate is recommended for children, and the dose of methotrexate must be adapted for adults. Inclusion of children in SFOP protocols and adults in EORTC and FNCLCC clinical trials is recommended; 5) treatment of metastatic osteosarcoma is based on chemotherapy and surgery to lung metastases which may be curative. Amputation is rarely appropriate. Inclusion of children in SFOP and of adult in EORTC and FNCLCC clinical trials for metastatic osteosarcoma is recommended; 6) at the present time, there are no clear data on which to base guidelines for timing and duration of follow-up studies in this condition.

Antineoplastic Agents↗
PubMed1999

Lifestyle modifications to prevent and control hypertension. 3. Recommendations on alcohol consumption. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada.

OBJECTIVE: To provide updated, evidence-based recommendations concerning the effects of alcohol consumption on the prevention and control of hypertension in otherwise healthy adults (except pregnant women). OPTIONS: There are 2 main options for those at risk for hypertension: avert the condition by limiting alcohol consumption or by using other nonpharmacologic methods, or maintain or increase the risk of hypertension by making no change in alcohol consumption. The options for those who already have hypertension include decreasing alcohol consumption or using another nonpharmacologic method to reduce hypertension; commencing, continuing or intensifying antihypertensive medication; or taking no action and remaining at increased risk of cardiovascular disease. OUTCOMES: The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered. EVIDENCE: A MEDLINE search was conducted for the period 1966-1996 with the terms ethyl alcohol and hypertension. Other relevant evidence was obtained from the reference lists of articles identified, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design, and graded according to the level of evidence. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension. BENEFITS, HARMS AND COSTS: A reduction in alcohol consumption from more than 2 standard drinks per day reduces the blood pressure of both hypertensive and normotensive people. The lowest overall mortality rates in observational studies were associated with drinking habits that were within these guidelines. Side effects and costs were not measured in any of the studies. RECOMMENDATIONS: (1) It is recommended that health care professionals determine how much alcohol their patients consume. (2) To reduce blood pressure in the population at large, it is recommended that alcohol consumption be in accordance with Canadian low-risk drinking guidelines (i.e., healthy adults who choose to drink should limit alcohol consumption to 2 or fewer standard drinks per day, with consumption not exceeding 14 standard drinks per week for men and 9 standard drinks per week for women). (3) Hypertensive patients should also be advised to limit alcohol consumption to the levels set out in the Canadian low-risk drinking guidelines. VALIDATION: These recommendations are similar to those of the World Hypertension League, the National High Blood Pressure Education Program Working Group on Primary Prevention of Hypertension and the previous recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control and the Canadian Hypertension Society. They have not been clinically tested. The low-risk drinking guidelines are those of the Addiction Research Foundation of Ontario and the Canadian Centre on Substance Abuse. SPONSORS: The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada. The low-risk drinking guidelines have been endorsed by the College of Family Physicians of Canada and several provincial organizations.

Adult↗
PubMed1999

Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP).

Routine vaccination of children is the most effective way to reduce hepatitis A incidence nationwide over time. Since licensure of hepatitis A vaccine in 1995, this strategy has been implemented incrementally, starting with the recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1996 to vaccinate children living in communities with the highest rates of infection and disease. These updated recommendations represent the next phase of this hepatitis A immunization strategy. Vaccination of children living in states and communities with consistently elevated rates of hepatitis A will provide protection from disease and is expected to reduce the overall incidence of hepatitis A. This report updates the ACIP's 1996 recommendations on the prevention of hepatitis A through immunization (MMWR 1996;45:[No. RR-151) and includes a) new data about the epidemiology of hepatitis A; b) recent findings about the effectiveness of community-based hepatitis A vaccination programs; and c) recommendations for the routine vaccination of children in states, counties, and communities with rates that are twice the 1987-1997 national average or greater (i.e., > or = 20 cases per 100,000 population) and consideration of routine vaccination of children in states, counties, and communities with rates exceeding the 1987-1997 national average (i.e., > or = 10 but <20 cases per 100,000 population). Unchanged in this report are previous recommendations regarding the vaccination of persons in groups at increased risk for hepatitis A or its adverse consequences and recommendations regarding the use of immune globulin for protection against hepatitis A.

Adult↗
PubMed1999

Clinical problem solving based on the 1999 Canadian recommendations for the management of hypertension.

The 1999 Canadian Recommendations for the Management of Hypertension are notable for the trends that they represent with regard to the evolution of the management of hypertension. Diagnostically, the Recommendations endorse the greater use of non-office-based measures of blood pressure control and greater emphasis on the assessment of other atherosclerotic risk factors, both when considering prognosis in hypertension and in the choice of therapy. On the treatment side of the equation, lower targets for blood pressure control have been advocated in subgroups of hypertensive patients, particularly in those with diabetes and renal disease. In conjunction with the recently published recommendations on lifestyle management, there is a greater emphasis on lifestyle modification, both as initial and adjunctive therapy in hypertension. Implicit in the recommendations for therapy is the principle that for the vast majority of hypertensive patients treated pharmacologically, practitioners should not follow a stepped-care approach. Instead, therapy should be individualized, primarily based on consideration of concurrent diseases, both cardiovascular and noncardiovascular (Tables 1 and 2). Through the consensus process, there was a general appreciation of how far we have come in the development of evidence-based recommendations for hypertension management. However, there was also an increasing appreciation of how far we have to go in effectively translating these recommendations into better blood pressure control.

Adult↗
PubMed1997

Consultant pharmacist drug therapy recommendations from monthly drug regimen reviews in a geriatric nursing facility: a two-year study and cost analysis.

PURPOSE: To analyze drug therapy recommendations acceptance or rejection costs in a nursing facility practice over 2 years. METHODS: Admission patient assessment, problem list and monthly problem-oriented drug regimen review (DRR) and assessment , with written report and mandated response by attending physician and follow-up on subsequent months DRR. Descriptive statistics of patient demographics and recommendation acceptance and types. Cost calculation of consequences of acceptance or rejection. SUMMARY OF RESULTS: In 204 predominantly female patients (age 83.7 +/- 7.8 years), with 4.5 +/- 1.3 active problems per patient, 4,008 monthly drug regimen reviews resulted in 374 recommendations (9.3% of reviews). In decreasing rank order, recommendations were for adverse drug reaction and interaction detection and resolution (156), discontinue medications (74), buspirone conversion from other psychotropic(s) (60), change medications (33), needed nutritional or drug therapy (26), change dose, dosing interval, dosage form, or administration technique (25). The cost savings from recommendation acceptance was $223,218; rejection $224,593. CONCLUSION: Geriatric long-term care patients appear to have numerous drug-related problems (DRPs) requiring unsolicited consultations, especially adverse drug reactions. Acceptance of consultant pharmacist recommendations may influence cost of overall care.

Aged↗
PubMed2000

Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria.

OBJECTIVE: The literature on unruptured intracranial aneurysms is reviewed, and an attempt is made to stratify it according to the weight of the evidence. Recommendations for surgery are suggested, using evidence-based criteria. METHODS: A MEDLINE search was performed for 1966 to 1999. The focus was restricted to surgical management rather than other types of management, such as endovascular treatments. Each article was classified as Class I, II, or III according to the weight of the evidence. Some articles, such as literature reviews and data analyses, did not fit this classification and were grouped separately. Recommendations are based on the evidence available. RESULTS: Forty-five articles were reviewed. Thirteen articles contained information on the natural history, 19 contained data on the risks of surgery, and 2 contained information on both. In addition, 11 contained analyses of costs and benefits. None met the criteria for Class I evidence. Seven articles on the natural history and 7 on the risks of surgery met the criteria for Class II evidence, and 6 and 12, respectively, met those for Class III evidence. The remainder of the articles were analyses or review articles. CONCLUSION: There is insufficient evidence to recommend a standard of management. As a therapeutic guideline, conservative treatment is recommended for small aneurysms (<10 mm) and asymptomatic nongiant aneurysms in older people, whereas surgery is recommended for larger aneurysms in younger people and symptomatic aneurysms in fit patients. Other recommendations can be justified only as therapeutic options, using evidence-based criteria. Areas for future investigation are discussed.

Evidence-Based Medicine↗
PubMed2000

[Standards, options, and recommendations for initial management of patients with malignant ovarian epithelial tumors].

UNLABELLED: Suprapubic and transvaginal pelvic ultrasound exploration is indicated for suspected ovarian tumor (standard). Diagnosis and search for extension require surgery and pathology examination. Systematic preoperative computed tomography is not recommended (standard). Surgery for cancer of the ovary is a specialized procedure requiring skill in cancer, gynecology, visceral surgery and laparoscopic surgery. If the patient is referred to a specialized center after a primary procedure considered to be inadequate, a new procedure is recommended for staging. Residual tumor volume after the primary procedure has prognostic value. Systematic second look procedures are not recommended for routine practice (standard). For patients with grade IA G1 tumors, there is no indication for complementary treatment (standard). For patients with grade IA G2-3 or clear cell tumors, IB, IC, IIA, there is no standard. OPTIONS: no complementary treatment, complementary chemotherapy using platinum, complementary external abdominopelvic radiotherapy. A complementary treatment is recommended for grades IC and IIA. Complementary treatment for grades IIB (no residual tissue), IIC (with residual tissue), III (no residual tissue), is based on: complementary chemotherapy with platinium, complementary external abdominopelvic radiotherapy (options). Complementary treatment for advanced forms (IIB (with residual tissue), IIC (with residual tissue), III (with residual tissue) and IV) is based on polychemotherapy with platinium (standard). OPTIONS: platinium combined with paclitaxel (intravenous), platinium combined with cyclophosphamide and/or doxorubicin (intravenous) or intraperitoneal cisplatin combined with cyclophosphamide (intravenous). The chemotherapy work-up includes physical examination, assay of serum markers (particularly CA125) and abdominopelvic computed tomography (proof level B) (standard). Physical examination is recommended for monitoring patients in complete remission with no sign of suspected recurrence (standard). This document was reviewed in April 1977. The working group again validated the Standards, OPTIONS and Recommendations, without modifications in June 1999.

Antineoplastic Agents, Hormonal↗