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PubMed2001

Recommendations for preventing transmission of infections among chronic hemodialysis patients.

These recommendations replace previous recommendations for the prevention of bloodborne virus infections in hemodialysis centers and provide additional recommendations for the prevention of bacterial infections in this setting. The recommendations in this report provide guidelines for a comprehensive infection control program that includes a) infection control practices specifically designed for the hemodialysis setting, including routine serologic testing and immunization; b) surveillance; and c) training and education. Implementation of this program in hemodialysis centers will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel. Based on available knowledge, these recommendations were developed by CDC after consultation with staff members from other federal agencies and specialists in the field who met in Atlanta on October 5-6, 1999. They are summarized in the Recommendations section. This report is intended to serve as a resource for health-care professionals, public health officials, and organizations involved in the care of patients receiving hemodialysis.

Bacterial Infections↗
PubMed1999

World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension-Do These Differ From the U.S. Recommendations? Which Guidelines Should the Practicing Physician Follow?

The recent World Health Organization-International Society of Hypertension (WHO-ISH) recommendations for the treatment of hypertension are consistent with the guidelines established by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) in the U.S. with several exceptions. Both reports define hypertension as a persistent elevation of blood pressure greater than 140/90 mm Hg and advocate the lowering of blood pressure for all patients with cardiovascular (CV) risk factors in addition to hypertension. The WHO-ISH report, however, suggests continuing monitoring without medication for subjects without other risk factors if pressures are not greater than 150/95 mm Hg. The JNC VI recommends drug therapy even in these subjects if blood pressures remain greater than 140/90 mm Hg after a 6-12 month period of nonpharmacologic interventions. Based on available data this would appear to be a more reasonable recommendation. The WHO-ISH indicates that all classes of medication are suitable initial therapy, despite the lack of morbidity and mortality data with several of them. The JNC VI continues to use outcome data to recommend diuretics or à -blockers as initial treatment. The WHO-ISH recommendations may prove to be appropriate-i.e., the lowering of blood pressure makes the difference and not which medication is used-There are some data to support this position but at present the strongest outcome data support the JNC VI recommendations. Both reports stress the importance of lowering blood pressure to levels of 130/85 mm Hg or even lower in patients with diabetes, renal, or heart failure. The addition of the WHO-ISH report should help to focus more clearly the need for better blood pressure control. (c)1999 by Le Jacq Communications, Inc.

Journal Article↗
PubMedDate not supplied

Competing demands in the office visit: what influences mammography recommendations?

BACKGROUND: The multiple competing demands of the busy office visit have been shown to interfere with delivery of preventive services. In this study we used physician recommendations for screening mammography to examine the relative importance of physician, patient, and visit characteristics in determining on which patient visits this preventive service will be provided. METHODS: Physicians in the Ambulatory Sentinel Practice Network (ASPN) completed a questionnaire describing their knowledge, attitudes, and beliefs about screening mammography. They also described the content of a series of nonacute care visits with women aged 40 to 75 years with regard to making a recommendation when the patient was due for screening mammography. The data were linked, and univariate and multivariate logistic regression methods were used to examine the relative importance of physician, patient, and visit characteristics on making a recommendation for mammography. RESULTS: Ninety-three physicians reported making a recommendation for screening mammography on 53.1% of nonacute visits. When modeling physician, patient, and visit characteristics separately, 70% of the variability in the model is explained by physician characteristics only, 63% by patient characteristics only, and 73% by visit characteristics only. A combined model using all characteristics explained 85% of the variability. CONCLUSIONS: Although characteristics of physicians and patients can predict frequency of recommendations for mammography, the specific characteristics of the visit are equally important. Efforts to improve delivery of preventive services in primary care that emphasize physician education and performance feedback are unlikely to increase rates of mammography recommendation. Effective strategies must consider the multiple competing demands faced by patients and physicians during each office visit and seek ways for assisting them in setting rational priorities for services.

Attitude of Health Personnel↗
PubMed2001

Infant sleep: resident recommendations and socioeconomic status differences in patient practices.

BACKGROUND: Although much research has focused on parental report of infant sleep position since the 1992 American Academy of Pediatrics (AAP) recommendation for non-prone placement, few studies have examined physician recommendations regarding infant sleep. This study examined differences between resident recommendations for infant sleep position and cosleeping (bed sharing) and parental report of practice. We also assessed socioeconomic differences in parent practice, awareness, and acceptability of AAP guidelines. METHODS: We conducted a telephone survey of parents of 2-, 4-, 8-, and 12-month-old infants from two family practice centers. All 27 residents at both centers completed a paper and pencil survey. RESULTS: Resident recommendations and parental practices differed significantly for both sleep positioning and cosleeping. Parents of 165 infants participated, revealing that higher socioeconomic families were more aware of compliant with, and more accepting of AAP recommendations for supine positioning. CONCLUSIONS: Parents consistently report that their physician or nurse is the primary source of information for infant sleep. Results of this study, however, indicate significant differences between physician recommendation and parental practice and acceptability of AAP guidelines. Physicians need to continue to discuss this information past the newborn period.

Child Rearing↗
PubMed2001

[Standards, options and recommendations: practice guidelines for difficult diagnosis in surgical pathology or cytopathology in cancer patients].

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. 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 the Standards, Options and Recommendations project for difficult diagnoses in surgical pathology or cytopathology in cancer patients. METHODS: Data were identified by searching Medline and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 71 independent reviewers. RESULTS: The main recommendations to prevent and reduce the number of difficult diagnoses in surgical pathology or cytopathology are: 1) The development of quality insurance programs with use of written procedures in each pathology laboratory (standard). 2) The knowledge of clinical data in order to explain surgical pathology or cytopathology results (standard). 3) The availability of complementary patient informations (radiologic data . . .) can be useful to explain surgical pathology or cytopathology results (option). The main recommendations to detect lesions associated with difficult diagnosis in surgical pathology or cytopathology are: 1) Tumor types known as potential difficult diagnosis in surgical pathology or cytopathology should be reviewed by a second pathologist. 2) The systematic second reviewing for every case is expensive but has to be done when the difficulty is know (sarcoma, lymphoma . . .) by experienced pathologists. The main recommendations to solve difficult diagnosis in surgical pathology or cytopathology are: 1) Block recuts, use of special techniques (immunocytohistochemistry and molecular biology), additional data from clinicians, second opinion by a local pathologist, or new specimen can be required for establishing the diagnosis (options). 2) Outside second opinion by expert pathologist has to be considered once the other steps did not allow to establish surgical or cytopathology diagnosis (recommendations, expert agreement).

Humans↗
PubMed2002

Community interventions to promote healthy social environments: early childhood development and family housing. A report on recommendations of the Task Force on Community Preventive Services.

The sociocultural environment exerts a fundamental influence on health. Interventions to improve education, housing, employment, and access to health care contribute to healthy and safe environments and improved community health. The Task Force on Community Preventive Services (the Task Force) has conducted systematic reviews of early childhood development interventions and family housing interventions. The topics selected provide a unique, albeit small, beginning of the review of evidence that interventions do effectively address sociocultural factors that influence health. Based on these reviews, the Task Force strongly recommends publicly funded, center-based, comprehensive early childhood development programs for low-income children aged 3-5 years. The basis for the recommendation is evidence of effectiveness in preventing developmental delay, assessed by improvements in grade retention and placement in special education. The Task Force also recommends housing subsidy programs for low-income families, which provide rental vouchers for use in the private housing market and allow families choice in residential location. This recommendation is based on outcomes of improved neighborhood safety and families' reduced exposure to violence. The Task Force concludes that insufficient evidence is available on which to base a recommendation for or against creation of mixed-income housing developments that provide safe and affordable housing in neighborhoods with adequate goods and services. This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and discusses implications for applying the interventions locally.

Child Development↗
PubMed2002

Health and medical informatics competencies: call to participate in updating the IMIA recommendations.

OBJECTIVES: On behalf of the International Medical Informatics Association (IMIA), its Working Group 1 (WG1) addresses health and medical informatics education. METHODS: As part of its mission, WG1 developed recommendations for competencies, describing a three-dimension framework and defining learning outcomes. RESULTS: Officially approved by IMIA in 1999, the recommendations have been translated into seven languages. In 2001, WG1 charged a small group with updating the recommendations and consider the work undertaken by others to develop competencies. Additional work underway in support of the recommendations includes a literature review to help extract the fundamental competencies from the recommendations. To ensure the highest quality of input in the updated recommendations, WG1 is issuing a call for participation to the international informatics community. CONCLUSIONS: Further work with the competencies will result in updated IMIA guidelines. These are expected to support the creation of a virtual university for health and medical informatics.

Curriculum↗
PubMed2002

Diet quality, nutrient intake, weight status, and feeding environments of girls meeting or exceeding the American Academy of Pediatrics recommendations for total dietary fat.

The American Academy of Pediatrics (AAP) recommends that children consume no more than 30% but no less than 20% of energy as dietary fat intake, and this recommendation is accompanied by suggestions that fat calories should be replaced by eating more grain products, fruits, vegetables, low fat dairy products, beans, lean meat, poultry, fish, and other protein rich foods. In comparing diets of girls meeting this AAP recommendation with girls who consumed diets higher in fat, we noted that girls meeting recommendations had diets that came closer to meeting other dietary recommendations for several food groups and had higher intake of several key micronutrients. Dietary fat was also associated with body fat and weight status. Children's fat intake was also related to mothers' dietary fat intake, and nutrient intake patterns were similar for mothers and daughters. Finally, mothers of girls consuming higher fat diets reported using more restriction and pressure to eat in feeding their daughters. These findings provide additional support for the AAP recommendation to limit total dietary fat. Findings reveal that mothers' use of controlling feeding practices are not effective in fostering healthier diets among children, and that mothers' own eating may be more influential than their attempts to control children's intake.

Adolescent↗
PubMed2002

Magnesium and trace elements in the elderly: intake, status and recommendations.

Imbalances between mineral intakes and recommended amounts have been observed in different groups of elderly subjects. Nevertheless, assessment of the status of magnesium and trace elements in the elderly is difficult, even for iron because infection and inflammation increases ferritin. Mineral bioavailability may change due to ageing. Therefore, formulation of mineral recommendations is complex and individual recommendations are sometimes necessary. A number of surveys show magnesium, zinc, selenium and chromium intakes by old persons to be lower than the corresponding reference nutrient intakes. Contrarily, intakes of iron are generally adequate or higher than recommended, and it has been suggested that increased storage of iron in the elderly may be related with the development of age-related diseases through the increase in oxidative stress. Low iron status together with iron excess may be common in an elderly population. The same applies for zinc. Magnesium and selenium deficiencies among the elderly are also well documented, especially among the institutionalised and people with pathologies. Chromium deficiency is associated with type II diabetes mellitus. Recommended iron intake is lower for elderly women compared to young, because menstruation ceases after menopause, but in old men, it is similar to that of young men. Dietary Reference Values for the rest of the elements are similar to those of adults, although several suggestions have been made about the quantities. This review examines various aspects of the changes in mineral bioavailability due to ageing, of data published on mineral intakes and status, and finally the dietary recommendations for this vulnerable population group.

Age Factors↗
PubMed2002

Folic acid and prevention of spina bifida and anencephaly. 10 years after the U.S. Public Health Service recommendation.

In September 1992, the U.S. Public Health Service (USPHS) recommended that all women capable of becoming pregnant should consume 400 microg of folic acid/day on an ongoing basis to reduce their risk for having a pregnancy affected by spina bifida and anencephaly (i.e., neural tube defects [NTDs]). The recommendation was preceded a year earlier by a CDC recommendation for women at high risk (i.e., those women who have had an earlier pregnancy affected by an NTD). The 1991 CDC recommendation stated that women at high risk should plan subsequent pregnancies and consume 4,000 microg/day of folic acid from the time they begin trying to become pregnant through the first trimester of pregnancy to reduce their risk. The 1992 USPHS recommendation specified that women at high risk should follow the general population recommendation for consumption of 400 microg/day when not trying to become pregnant.

Anencephaly↗
PubMed2001

A comparison of recommended and reduced insecticide regimes in alfalfa.

The objective of this study was to evaluate the effects of the recommended rates of insecticides applied at two different population levels of the alfalfa weevil, Hypera variabilis Hbst. (Coleoptera: Curculionidae) and the reduced levels of insecticides on alfalfa weevil, predators and yield in 1998 and 1999. More specific objective was to search for options to reduce insecticide usage while implementing an effective pest control, thereby developing more economically and environmentally sound alfalfa production systems. The treatments used included: i) recommended rate insecticide (malathion) at population level of 5 weevils/sweep, ii) recommended rate at population level of 10 weevils/sweep, iii) 50% of recommended rate at population level of 10 weevils/sweep, iv) stripe spray of 50% rate at population level of 10 weevils/sweep, where insecticides were applied only on 0.5 m stripes in plots while the next 0.5 m stripes were not treated and v) control. The results indicated that the recommended rate insecticide application at 5 weevils/sweep level provided the highest reduction in the weevil densities in both years. No significant differences occurred among the weevil densities in the plots received the recommended rate, the 50% rate and the stripe spray insecticide treatments at 10 weevils/sweep level. Predators were in general more abundant in the insecticide treated plots compared to the control. The insecticide applications, except the stripe spray in 1999, led to increases in yields.

Animals↗
PubMed2003

Patients' recommendation of doctor as an indicator of patient satisfaction.

OBJECTIVES: To determine whether patients' recommendation of their family doctor to others correlates with patient satisfaction scores, and to investigate other factors influencing patients' recommendation of doctor. DESIGN: Self-administered patient questionnaire. SETTING: Thirty-six family practice clinics, Slovenia. PATIENTS AND METHODS: A total of 2160 consecutive adult patients attending the clinics were approached to complete a self-administered questionnaire, to be returned in a prepaid envelope. The questionnaire included validated tools, such as the EUROPEP questionnaire on patient satisfaction and gathered data on health-related quality of life, patient demographic, socio-economic and health characteristics, and attitudes and experience of health services. Patients also selected a response to the statement "I can strongly recommend my family doctor to my friends" on a five-point scale, from strongly disagree to strongly agree. RESULTS: Overall, 92% of respondents were in agreement with the statement that they would strongly recommend their family doctor to their friends. Patient satisfaction in the group of patients strongly agreeing with the statement was 11.1 points higher than that for the group responding they agreed only (92.4 versus 81.3 points; P<0.001). Multivariate analysis showed that 51.5% of the variation in the response to the statement could be explained by patient, doctor, and practice characteristics investigated. CONCLUSION: Higher agreement with the statement "I can strongly recommend my family doctor to my friends" was shown to be associated with higher patient satisfaction with the doctor's working style, with some patient demographic characteristics, aspects of patients' health care utilisation, and some doctor characteristics. Using a simple question regarding recommendation of the doctor to friends can be used as a surrogate measure of patient satisfaction, but should be interpreted with caution.

Family Practice↗
PubMed2003

Colorectal cancer screening among African Americans: the importance of physician recommendation.

INTRODUCTION: African Americans have higher colorectal cancer incidence and mortality rates than whites. They are also more likely to be diagnosed with late-stage disease and less likely to survive for at least five years after diagnosis. Lack of adherence to colorectal cancer screening recommendations has previously been found to be associated with lower income, lower educational level, and racial/ethnic minority status. METHODS: One hundred-fifty African-American patients (aged 50-79 years) of an inner city hospital, were surveyed by mail and telephone in early 2002. Seventy-six patients completed the survey, and data from 74 surveys were analyzed. RESULTS: Approximately one-half (55%) of the respondents reported having received a fecal occult blood test (FOBT) in the last 12 months, sigmoidoscopy in the last five years, or colonoscopy in the last 10 years. Thirty-nine percent of the survey participants reported never having received a physician recommendation for FOBT, 60% reported never having received a recommendation for sigmoidoscopy, and 57% reported never having received a recommendation for colonoscopy. Previous physician recommendation was strongly associated (p < 0.001) with levels of FOBT, sigmoidoscopy, and colonoscopy use. DISCUSSION: Future studies should examine factors that influence primary care physicians' decision-making about ordering colorectal cancer screening tests, as well as patients' decision-making regarding adherence to physician recommendations.

Black or African American↗
PubMed2003

Comprehensive categorization of guideline recommendations: creating an action palette for implementers.

Transforming guideline recommendations into executable statements for computerized decision support systems requires a clear understanding of what tasks must be performed. We sought (a) to determine whether a limited set of action types could be defined to comprehensively categorize activities recommended by the majority of clinical guidelines, (b) to describe the relative frequency of these action types, and (c) to create a library of recommendations for future validation activities. We randomly selected test and validation sets of 50 recommendations each from the National Guideline Clearinghouse and randomly extracted 3 recommendations from each guideline. We tested the ability of a preliminary palette of action types to categorize guideline-prescribed activities and expanded it to accommodate several unanticipated actions. Ultimately, the following actions were sufficient to categorize all 405 actions: Prescribe, Perform therapeutic procedure, Educate/Counsel, Test, Dispose, Refer/Consult, Conclude, Monitor, Document, Advocate, Prepare, and No recommendation., and Prepare. Thus, we define a set of terms that can facilitate guideline implementation in clinical information systems. These action types can be used to construct a framework for design of clinical decision support systems.

Decision Making, Computer-Assisted↗
PubMed2004

Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.

This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2-10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized. In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.

Adenovirus Infections, Human↗
PubMed1992

[Dietary intake recommended for elderly persons].

Recommendations for dietary intake in elderly persons must account for wide interindividual variation. We propose different recommendations for: generally self sufficient elderly persons in good health. The recommended dietary intakes are very similar to those for adults, with a few exceptions (reduced calorie intake, the importance of protein and certain vitamins or minerals: vitamins B6, D, C, calcium, zinc ...); patients with an intercurrent disease or an event causing a loss of appetite and a reduction in dietary intake. Recommendations for these subjects should aim at correcting or preventing deficiencies by the use of supplementary and complementary nutritional products; subjects in a state of protein-calorie malnutrition. Recommended dietary intake should take into account the effect of malnutrition on the digestive functions of the pancreas and the intestine in the elderly. Such recommendations must be based on the findings of numerous studies now being carried out and of which we report here the first results.

Aged↗
PubMed2000

Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP).

These recommendations of the Advisory Committee on Immunization Practices (ACIP) for poliomyelitis prevention replace those issued in 1997. As of January 1, 2000, ACIP recommends exclusive use of inactivated poliovirus vaccine (IPV) for routine childhood polio vaccination in the United States. All children should receive four doses of IPV at ages 2, 4, and 6-18 months and 4-6 years. Oral poliovirus vaccine (OPV) should be used only in certain circumstances, which are detailed in these recommendations. Since 1979, the only indigenous cases of polio reported in the United States have been associated with the use of the live OPV. Until recently, the benefits of OPV use (i.e., intestinal immunity, secondary spread) outweighed the risk for vaccine-associated paralytic poliomyelitis (VAPP) (i.e., one case among 2.4 million vaccine doses distributed). In 1997, to decrease the risk for VAPP but maintain the benefits of OPV, ACIP recommended replacing the all-OPV schedule with a sequential schedule of IPV followed by OPV. Since 1997, the global polio eradication initiative has progressed rapidly, and the likelihood of poliovirus importation into the United States has decreased substantially. In addition, the sequential schedule has been well accepted. No declines in childhood immunization coverage were observed, despite the need for additional injections. On the basis of these data, ACIP recommended on June 17, 1999, an all-IPV schedule for routine childhood polio vaccination in the United States to eliminate the risk for VAPP. ACIP reaffirms its support for the global polio eradication initiative and the use of OPV as the only vaccine recommended to eradicate polio from the remaining countries where polio is endemic.

Child↗
PubMed1992

Recommendations of the German Association for Medical Informatics, Biometry and Epidemiology for education and training in medical informatics.

In the fields of health care and medicine there is an immense demand for a systematic application of methods of information processing and for the use of computers. Obviously, to that end well-trained scientists and qualified personnel must be available. With the present recommendations on education and training in medical informatics the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) proposes structure and contents of medical informatics curricula and courses. The recommendations describe a 2-dimensional educational framework with different education levels in one dimension and various types of educational needs and orientation in the other one. The recommendations comprise at the university level education as well specialized curricula covering the total spectrum of medical informatics as well as informatics curricula with medical informatics as integrated applied subject or subsidiary subject, respectively. Besides these informatics-oriented approaches medical-oriented programs of education in medical informatics are recommended, e.g., post-graduate education in medical informatics for physicians based on foundations in medical informatics as part of their initial training in medicine. At the level of polytechnical schools curricula of medical documentation and informatics and at the level of professional schools training in medical documentation are recommended. This report is a translation of its German original. Although considered by the GMDS as recommendations for the Federal Republic of Germany, the text may also contribute to the development of an international, especially European framework of training in medical informatics.

Germany↗