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PubMed2005

Evaluation and management of apparent life-threatening events in children.

Apparent life-threatening event syndrome predominantly affects children younger than one year. This syndrome is characterized by a frightening constellation of symptoms in which the child exhibits some combination of apnea, change in color, change in muscle tone, coughing, or gagging. Approximately 50 percent of these children are diagnosed with an underlying condition that explains the apparent life-threatening event. Commonly, the problems are digestive (up to 50 percent), neurologic (30 percent), respiratory (20 percent), cardiac (5 percent), and endocrine or metabolic (less than 5 percent). Fifty percent of these events are idiopathic, which causes great concern to parents and physicians. The evaluation of an affected infant involves a thorough description of the event as well as prenatal, birth, medical, social, and family history. The physical examination, including careful neurologic examination and notation of any apparent anatomic abnormalities, helps diagnose congenital problems, infection, and conditions contributing to respiratory compromise. The laboratory evaluation is driven by historical and physical findings. Inpatient evaluation and monitoring are recommended in virtually all cases unless investigations are normal. Should the history reflect a severe episode, or should the child require major interventions such as cardiopulmonary resuscitation, inpatient observation and monitoring are recommended, even if physical examination and laboratory findings are normal. Once a presumptive diagnosis is made, events should cease after appropriate intervention. If not, reviewing the history, performing another physical examination, and reassessing the need for laboratory and imaging studies are the next steps. Although consensus statements by the National Institutes of Health and the American Academy of Pediatrics support home monitoring, the relationship of apparent life-threatening event syndrome to sudden infant death syndrome is controversial.

Apnea↗
PubMed2005

Clinical quality indicators of venous leg ulcers: development, feasibility, and reliability.

In the clinical setting, diagnosis and treatment of venous leg ulcers can vary considerably from patient to patient. The first step to reducing this variation is to document venous leg ulcer care through use of quantitative scientific documentation principles. This requires the development of valid and reliable evidence-based quality indicators of venous leg ulcer care. A Scandinavian multidisciplinary, cross-sectional panel of wound healing experts developed clinical quality indicators on the basis of scientific evidence from the literature and subsequent group nominal consensus of the panel; an independent medical doctor tested the feasibility and reliability of these clinical indicators, assessing the quality of medical technical care on 100 consecutive venous leg ulcer patients. Main outcome measures were healing, recurrence, pain, venous disease diagnosis, differential diagnosis and treatment, and inter- and intra-rater reliability. The indicators proved feasible and reliable to measure (inter-rater kappa = 0.79, P < 0.01 and intra-rater kappa = 0.89, P < 0.1). Within 3 months of initial examination, venous etiology was verified by duplex in 61 of the 98 participating patients (62%) and 31 (32%) were assessed for venous surgery. Distal arterial pressure was measured following initial examination in 33 of the patients (34%). All patients (100%) were prescribed compression therapy. Of the 98 patients, 11 (11%) had ulcers recur in 3 months and 72 (73%) healed in 12 months, which is in line with the literature. It is feasible to reliably measure the quality of medical technical venous leg ulcer care in the clinical setting using a few strategic clinically relevant indicators of quality.

Aged↗
PubMed2005

Atrial fibrillation following cardiac surgery.

Atrial tachyarrhythmias, usually atrial fibrillation or atrial flutter, are the most common complications of cardiac surgery. Atrial tachyarrhythmias are associated with patient discomfort/anxiety, hemodynamic deterioration, cognitive impairment, thromboembolic events (including stroke), exposure to the risks of antiarrhythmic treatments, longer hospital stays and increased costs. Many approaches to the prevention of postoperative atrial tachyarrhythmias have been studied. Of these, studies using perioperative beta-blocking agents or amiodarone provide level A evidence of efficacy and, in properly selected patients, have shown a high degree of safety. Less convincing, level B evidence exists for the use of postoperative temporary atrial pacing and for perioperative intravenous magnesium treatment. The treatment of postoperative atrial tachyarrhythmias is similar to those occurring in other settings and includes excluding other potential causes of atrial tachyarrhythmias, antithrombotic or anticoagulation therapy, control of the ventricular response rate and consideration of restoring/maintaining sinus rhythm. The selection of therapies to achieve these goals should consider the sympathetic nervous system discharge state of the postoperative environment and the natural history of postoperative atrial fibrillation, which includes spontaneous resolution of the arrhythmogenic tendency after approximately six weeks. The Canadian Cardiovascular Society Consensus Conference recommendations for the prevention of atrial tachyarrhythmias after cardiac surgery and for the treatment of atrial tachyarrhythmias that occur after cardiac surgery are presented along with evidence that supports these recommendations.

Atrial Fibrillation↗
PubMed2005

[Viral hepatitis: Croatian consensus statement].

There has been a dramatic improvement in diagnostic procedures and therapy of viral hepatitis in the last 20 years. Improvements in therapy caused an increase in actual cost, however, with significant long-term savings through a decreased cost of treatment of advanced liver disease including liver transplantation. The Croatian National Board for Viral Hepatitis has decided to initiate the organization of consensus conference on viral hepatitis enabling the leading experts in the country to give the best possible recommendations for the diagnosis, prophylaxis and therapy in our circumstances. The Consensus Conference took place in Zagreb in June 2004, with update in March 2005, organized by the Croatian National Board for Viral Hepatitis, Reference Centers of the Ministry of Health for Chronic Liver Diseases, Infectious Diseases and AIDS, Croatian Society of Gastroenterology--Hepatology Section, Croatian Society for Nephrology, Dialysis and Transplantation, and Croatian Institute for Health Insurance. Invited experts provided written reports on the respective subjects that appear in this issue and their recommendations resulting in this consensus statement.

Consensus Statements as Topic↗
PubMed2005

[Consensus-based guidelines on prostate biopsy].

OBJECTIVE: To develop evidence-based and consensus-based guidelines, helping physicians to take decisions about diagnostic procedures for men wishing to undergo examination for detection of prostate cancer. MATERIAL AND METHODS: A panel of multidisciplinary Italian experts in urology, medical oncology, laboratory medicine, radiotherapy, pathology and methodologists for clinical trial (Mario Negri Institution) grouped together in 2002 to address specific questions relating to clinical controversies in prostate cancer diagnosis. A practitioners feedback survey by means of a questionnaire of 49 items was also conducted in 2003 to assess the great variability in all the aspects relating a prostate biopsy (PB). Experts reviewed relevant evidence, using CeVEAS scale, of the literature from 1966 to December 2004 (Medline, Embase, Cochrane library) before offering the discussion panel proposed guidelines for a given subset of questions. The discussion panel, which consisted of presenters and representatives from medical oncology, forensic medicine, radiotherapy, ethics, biochemistry and family practice medicine, took place on February 12, 2005 in Bologna. The panel deliberated to reach consensus on suggested guidelines. When evidence was insufficient, suggested guidelines represent the opinion of a cross-section of the presenters and discussion panel. RESULTS: Consensus was achieved regarding all the aspects relating PB. The final paper was approved by the jury, the panel of experts and the audience. A standardized guideline, containing a short version for physicians and a standardized patient information booklet, for nation-wide use was developed. In the final document it has been reported as following: Prostatic biopsy (PB) is recommended in all patients with a PSA> = 4.0 ng/ml (2,5 ng/ml in patients with positive family history), abnormal DRE and %FPSA < 10%. PSAD and PSAV are considered controversial predictive factors. Antibiotic prophylaxis with a fluoroquinolone, which can be omitted in cases of transperineal (TP) PB, is mandatory when using a transrectal (TR) approach. It is necessary to start the prophylaxis the day before and continued for 2-3 days after the procedure. Anaesthesia is mandatory in case of TP biopsy and strongly recommended in cases of TR PB (10 cc of periprostatic lidocaine injection rather than intrarectal lidocaine gel). The optimal PB scheme should include more than 6 cores (preferably 10-12 cores) weighted more laterally and apically. PB directed only to the hypoechoic lesion or standard sextant biopsy (Hodge's scheme) are considered obsolete. PB of the transition zone are mandatory only in cases of re-biopsy. A tru-cut needle with a diameter of 18 Fr. is recommended and a sandwich technique for core fixation informalin is considered the optimal approach. A PB should be repeated within 6-12 months in the following cases:1) First biopsy is inadequate (less than 6 cores, absence of prostatic cells on the cores), 2) in presence of HGPIN, ASAP or both on first PB, 3) in cases with persistently high levels of PSA (PSA > 10 ng/ml or PSA velocity > 0,75 ng/ml/year). PB after radiotherapy is not routinely indicated as well as biopsy of the vesico-urethral anastomosis after radical prostatectomy in patients with PSA failure. CONCLUSIONS: The suggested guidelines represent a reasonable diagnostic approach in patients to be submitted to PB, with the understanding that new data, subsequent findings, or other methodological considerations may lead to future modifications.

Biopsy↗
PubMedDate not supplied

Should health care assistants apply compression bandages?

In 2004 the Leg Ulcer Forum issued a consensus statement, which stipulated that health care assistants should not apply compression bandaging. Because concerns have been raised about the role of unqualified staff in general wound management, the forum's executive has reissued the statement.

Bandages↗
PubMedDate not supplied

[The treatment of multiple sclerosis in Latin America: current practice and optimal standards. The findings of a survey among neurologists at an interactive workshop].

INTRODUCTION: Considerable progress has been made in the treatment of patients with relapsing-remitting multiple sclerosis (MS) over the last decade. Exactly how these changes are reflected in daily practice, however, is still not very well known. AIM: To hold interactive workshops so as to be able to evaluate the opinions of Latin-American neurologists about the therapeutic decisions taken with regard to MS. MATERIALS AND METHODS: By means of an interactive voting system, professionals attending each workshop replied to ten pre-established questions about when to start treatment, the use of magnetic resonance imaging (MRI) to supervise treatment, the definition of therapeutic failure and the role of treatment using immunosuppressants. The results were compared with those obtained in similar workshops attended by European and North American neurologists held six months earlier. RESULTS: The use of immunomodulators was considered to be useful in isolated demyelinating syndromes, as 40-50% endorsed their use in clinically stable patients. MRI was seen to be the most sensitive method of monitoring the effectiveness of the therapy -70.6% of them proposed the application of annual scans, which suggests a more frequent use in Latin America than in Europe or the USA. On defining therapeutic failure, the clinical criteria were more important than the MRI scan, and a switch from beta interferons to glatiramer acetate or vice versa was recommended. Treatment with immunosuppressants was considered to be useful in reducing the accumulated disability, but there was no agreement on how to use them. In Latin America, decisions about when to begin treatment seem to lie somewhere between the more favourable posture adopted in USA and the more conservative stance in Europe. CONCLUSIONS: This survey reflects the controversies that affect the therapeutic decisions concerning MS in Latin America and highlights the areas in which more data are needed to optimise the standards of treatment.

Consensus Statements as Topic↗
PubMed2006

[Tools for assessing healthcare delivery].

INTRODUCTION: Assessing the quality of care has become an essential part of the medical process. In France, the Professional Practice Evaluation requires a sound knowledge of these techniques. BACKGROUND: The different tools that can be used to carry out quality assessment are presented, with their specific applications. Two main categories can be used. The first are information synthesis techniques such as consensus conferences, practice guidelines, and panellist's appropriateness rating. The second category is based on comparison to a reference: clinical audit, targeted clinical audit, or appropriateness evaluation protocols. Other, less commonly employed approaches include a problem solving approach, which is often included in total quality management, clinical care pathway, risk management, mortality morbidity conference, adverse event monitoring, and statistical process control charts. VIEWPOINT: These tools will be widely used in the next few years, because the recent changes in French law could increase their use. CONCLUSION: A good knowledge of these techniques is needed in order to improve quality assessment.

Consensus Statements as Topic↗