The development of clinical practice guidelines for treatment of peptic acid diseases in a VA ambulatory care clinic

The costly treatment of peptic acid diseases at a Veterans Affairs ambulatory care clinic prompted the development of clinical practice guidelines (CPGs) for the disorders. A committee consisting of a clinical pharmacist, the chiefs of ambulatory care and medicine, and a gastroenterologist guided the process. A consensus-style conference format involving medical staff and residents, pharmacists, and other health providers was chosen to develop the CPGs. Before the conference each participant received a list of key issues and literature on practice guidelines, and on peptic acid diseases and their treatment. At the conference the participants were divided into four groups; each group discussed specific key issues using a modified nominal group process. Recommendations from each group were made to the entire conference. Final recommendations were compiled into what was adopted and readily received as the CPGs for the institution.     

Topical calcitriol in the treatment of chronic plaque psoriasis: a double-blind study

A randomized, double-blind, left-right, vehicle-controlled study to assess the therapeutic efficacy and safety of twice daily application of 15 micrograms/g calcitriol ointment for a period of 6 weeks was performed in 32 patients suffering from bilateral, symmetrical, severe chronic plaque psoriasis. Twice daily 15 micrograms/g calcitriol ointment significantly improved erythema, induration, scaling and global severity of psoriatic plaques, and was much more effective than vehicle ointment. The difference in overall clinical efficacy between calcitriol and vehicle was statistically significant from week 1 onwards, and was maintained over the entire study. On completion of the study, clearance of psoriatic lesions was found in 47% of calcitriol-treated sides and in 13% of vehicle-treated sides. Skin histopathology of calcitriol-treated sides revealed a return to normal keratinization, with decreased inflammatory cell infiltration in the dermis and disappearance of the inflammatory infiltrate from the epidermis. Three patients had asymptomatic hypercalcaemia during the study. Mean serum levels of total calcium, albumin-adjusted total calcium, phosphorus, 25-hydroxyvitamin D and calcitriol did not show statistically significant changes in the baseline/end-point comparisons.     

A normative analytic framework for development of practice guidelines for specific clinical populations

BACKGROUND: A central problem in practice guideline development is how to develop guidelines that appropriately account for variations in clinical populations and practice settings. Despite recognition of this problem, there is no formal mechanism for assessing what the need is for flexibility in guidelines, or for deciding how to incorporate such flexibility into recommendations. OBJECTIVE: This research sought to provide a formal basis to determine when clinical circumstances vary sufficiently that guideline recommendations should differ, how recommendations should be tailored for a specific clinical setting, and whether the benefit associated with such site-specific guidelines justifies the expense of their development. RESULTS: The authors describe an approach for estimating the maximum health benefit that developers can obtain by eliminating uncertainty about differences in the patient populations and practice settings in which a guideline will be used. This estimate, the expected value of customization, provides a mechanism to evaluate the cost-effectiveness of the development of site-specific guidelines that account explicitly for variation in clinical circumstances. Application of this method to the development of screening guidelines for human immunodeficiency virus (HIV) infection indicates that the development of site-specific guidelines potentially is cost-effective. Site-specific guidelines either improve, or leave unchanged, the efficiency of HIV screening; whether they increase or decrease total expenditures and health benefits depends on the choice of a cost-effectiveness threshold, and the clinical problem. CONCLUSIONS: Development of guideline recommendations based on decision models provides a normative approach for evaluating the need for and the cost-effectiveness of site-specific guidelines that have been tailored to specific practice settings. Such site-specific guidelines can improve substantially the expected health benefit and the economic efficiency of practice guidelines.     

The effects of oral liarozole on epidermal proliferation and differentiation in severe plaque psoriasis are comparable with those of acitretin

The imidazole derivative liarozole is a potent inhibitor of cytochrome P450-dependent 4-hydroxylation of endogenous all-trans retinoic acid, thereby increasing the levels of all-trans retinoic acid in both plasma and skin. As part of a large, double-blind, randomized clinical study, we investigated the cell biological alterations in uninvolved and lesional skin of 20 patients with severe plaque psoriasis, who were treated with either liarozole or acitretin. The extent and severity of the skin lesions, as recorded by the Psoriasis Area and Severity Index score, was significantly reduced (P 相似文献   

The variable response of plaque psoriasis after a single treatment with topical 5-aminolaevulinic acid photodynamic therapy

We have investigated the clinical response of 22 patients with plaque psoriasis to photodynamic therapy using topical application of 5-aminolaevulinic acid followed by a single exposure to broad-band visible radiation. Light doses in the range 2-16 J/cm2 delivered at dose of 10-40 mW/ cm2 resulted in a variable clinical response. Seven (35%) patients showed clearing of psoriasis at some treated sites. The intensity of protoporphyrin IX fluorescence was recorded before, during and after treatment. Pre-illumination fluorescence intensity varied considerably between sites on the same patient and between patients. Protoporphyrin IX fluorescence recovered and persisted after treatment for up to 14 days and became higher than preillumination levels at 25% of sites. The rate of protoporphyrin IX photo-oxidation during treatment was proportional to both initial fluorescence intensity and incident light dose rate and was almost complete after 16 J/cm2. We have defined the photodynamic dose as the product of time-dependent protoporphyrin IX concentration and light dose and demonstrated that only in those patients who showed clearance of psoriasis was there a relationship between photodynamic dose and clinical response. Discomfort ranged from stinging through to burning, was significant in some patients and tended to be more severe with increasing photodynamic dose but was not predictable. Efficacy may improve by achieving consistent protoporphyrin IX levels or by using multiple treatments.     

Enhancing clinical practice: The role of practice guidelines.

Health service researchers believe that significant practice variations occur, in part, because there is no strong consensus on best practices for managing a specific condition. The Agency for Health Care Policy and Research supports the development of science-based clinical guidelines, performance measures, and standards of quality. Since 1992, it has published 6 clinical guidelines and is supporting development of more than 20 others. Each has a consumer version, in English and Spanish, to educate patients and describe care options. Widespread use of these guidelines will improve the quality of health care by assisting providers in making more informed decisions, thereby reducing unnecessary health care practices; will reduce some costs; and will provide feedback on knowledge gaps that merit the attention and support of researchers and policymakers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The legal implications of clinical practice guidelines

In the past several years, considerable attention has been focused on clinical practice guidelines. They are developed to foster improved clinical care and to increase clinical efficiency. The legal implications of developing and following guidelines are not yet clear. The author argues that properly formulated guidelines could reduce the burdens of preventing and resolving malpractice claims.     

The development of guidelines for the management of concussion in sports

The usage of laser correlation spectroscopy for verification of preclinical and clinical states is substantiated. Developed "semiotic" classifier for solving the problems of preclinical and clinical states is presented. The substantiation of biological algorithms as well as the mathematical support and software for the proposed classifier for the data of laser correlation spectroscopy of blood plasma are presented.     

The intentional mentor: Strategies and guidelines for the practice of mentoring.

How can faculty in professional psychology programs become more intentional and effective mentors? Many psychology graduate students are never mentored, and very few psychologists have ever received training in the practice of mentoring. This article briefly summarizes the nature of mentoring, the prevalence of mentoring in psychology, primary obstacles to mentoring, and some ethical concerns unique to mentoring. The article provides several strategies to enhance mentoring and guidelines for the profession, departments of psychology, and individual psychologists who serve as mentors. This article is designed to help readers take a more deliberate approach to the practice of mentoring. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Educational practice guidelines for a surgical clerkship

Similar to the Residents Review Committee's "Essentials for a Residency Training Program," this article provides Educational Practice Guidelines for a required surgical clerkship. The Guidelines presented are ones that can be adopted by any department of surgery in the United States, but in some cases not without significant increase in resources and faculty effort. The 10 essential components provide an opportunity for intensive program evaluation of all medical student clerkship experiences.     

The use of empiric clinical data in the evaluation of practice guidelines for unstable angina

OBJECTIVE: To determine the applicability to emergency department (ED) clinical practice of a nationally disseminated practice guideline on the disposition of patients with a diagnosis of unstable angina, and to determine the potential impact of the guideline on hospital admissions and demand for intensive care beds. DESIGN: Application of guideline criteria for ED disposition decisions to a validation sample derived from a prospective clinical trial. SETTING: Five hospitals, including 2 urban general teaching hospitals, 2 urban tertiary care university hospitals, and 1 suburban university-affiliated community hospital. PATIENTS: A consecutive sample of 457 patients who presented with symptoms suggestive of acute cardiac ischemia and who had "unstable angina" or "rule out unstable angina" diagnosed by ED physicians. Greater than 90% of eligible patients were enrolled in the clinical trial; follow-up data sufficient for assignment of a definitive diagnosis were obtained for 99% of subjects. MAIN OUTCOME MEASURES: Acute myocardial infarction and unstable angina, based on blind review of initial and follow-up clinical data, including cardiac enzyme levels and electrocardiograms. After completion of the trial, without knowledge of final diagnosis or outcome, the investigators classified patients into risk groups specified by the unstable angina guideline. RESULTS: Of subjects with an ED diagnosis of unstable angina, only 6% (n=28) met the guideline's criteria corresponding to low risk for adverse events and were therefore suitable for discharge directly to home. Fifty-four percent (n=247) met the intermediate-risk criteria; 40% (n=182) met the high-risk criteria and were identified as requiring admission to an intensive care unit. Actual ED disposition differed from guideline recommendations in 2 major areas: only 4% (1/28) of low-risk patients were discharged to home with outpatient follow-up, and only 40% (72/182) of high-risk patients were admitted to an intensive care unit. CONCLUSIONS: Although the guideline was intended to reduce hospitalization by identifying a low-risk group, the small size of this group among ED patients suggests that little reduction in hospitalization can be expected. Indeed, the guideline may increase demand for the limited number of intensive care beds to accommodate patients with unstable angina considered high-risk but currently placed elsewhere. These results emphasize the need to use empiric data from target clinical settings to assess the likely actual impact of guidelines on clinical care prior to national dissemination.     

Current treatment guidelines for acromegaly

Acromegaly, an indolent disorder of growth hormone (GH) hypersecretion is most typically caused by a somatotroph cell adenoma and may be treated by several modalities. Transsphenoidal surgical resection of micro-adenomas by experienced neurosurgeons results in biochemical normalization (postglucose GH <2 ng/mL, assay-dependent, age- and sex-matched IGF-I levels) in 70% of patients. However, over 65% of GH-secreting adenomas are invasive or macroadenomas, and over 50% of these patients have persistent postoperative GH hypersecretion. Irradiation of adenomas results in attenuation of GH secretion to more than 5 ng/mL in 50% of subjects after 12 yr. However, the percent of parents who normalize IGF-I levels is less certain. Most of these patients develop associated pituitary failure and rarely develop other local adverse effects. About 60% of patients receiving somatostatin analogs achieve normalized IGF-I levels. Efficacy of medical management with somatostatin analogs may be improved by increasing injection frequency, changing delivery modes to depot preparations, and in the future, development of novel SRIF receptor subtype-specific analogs. An integrated approach to acromegaly management based upon relative risks and benefits of the currently available therapeutic modes is presented that allows for a national individualized strategy designed to achieve maximal biochemical control of GH hypersecretion and elevated IGF-I levels.     

Treatment of psoriasis in general practice

Psoriasis is a chronic skin disease which affects about 2% of the population. Several new treatment modalities have been introduced in recent years. This article focuses on topical treatment of mild and moderate psoriasis that can be successfully treated at home. It is important that general practitioners who treat most of these patients are familiar with the best treatment procedures. Phototherapy and systemic therapy, mainly by dermatologists, are described in brief.     

Fifteen years with clinical guidelines in the treatment of hypertension--still discrepancies between intentions and practice

Live-donor kidney transplants accounted for only 27% of all kidney transplants performed in the United States in 1995. Prolonged hospitalization, pain, extended convalescence, and related socioeconomic concerns associated with traditional open-donor nephrectomy surgery may discourage potential donors, contributing to a low percentage of live kidney donors. To remove such disincentives, the laparoscopic live-donor nephrectomy procedure was introduced. In this study, the post-discharge course of 10 laparoscopic nephrectomy donors was compared with that of 27 open nephrectomy donors over the same time period. Laparoscopic nephrectomy donors experienced significantly shorter hospitalizations, less pain, felt able to return to work and normal routines sooner, and needed significantly less assistance during the recuperation period than did open nephrectomy donors. The laparoscopic nephrectomy procedure may decrease many of the concerns of potential donors, thus making live kidney donation more attractive and increasing the kidney supply.     

Hyperthermia in the treatment of psoriasis

The effectiveness of commercially available, chemically generated, topical exothermic pads that elevate skin surface temperature from 42 to 43 degrees C was stressed in 22 patients with psoriasis. Control sites were treated with conventional modalities such as Goeckerman's regimen, as well as with occlusion with nonexothermic pads. Skin lesions in 19 patients disappeared after the use of hyperthermia. The average time required for complete regression in the treated areas was 27 days with hyperthermia, compared with 44 days with Goeckerman's regimen. There were no hyperthermic side effects. Seventeen patients whose skin lesions disappeared with the use of both hyperthermia and Goeckerman's regimen were subsequently reexamined. The hyperthermia produced an equal or longer duration of remission than did Goeckerman's regimen.