UK clinical guideline for the prevention and treatment of osteoporosis Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department. Can intensive three-day programmes improve nurses' communication skills in cancer care? Prophylaxis of chemotherapy-induced febrile neutropenia with granulocyte colony-stimulating factors: where are we now? A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Hand hygiene: Attitudes and practices of nurses, a comparison between 2007 and 2015 The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events NICE guidance on reducing the risk of venous thromboembolism in patients admitted to hospital They think they know but do they? Misalignment of perceptions of lifestyle modification knowledge among health professionals. A cluster randomised controlled trial of nurse and GP partnership for care of Chronic Obstructive Pulmonary Disease Lack of compliance of staff in an intervention study with focus on nutrition, exercise and oral care among old (65+ yrs) Danish nursing home residents Problems with clinical trials in general practice--a double-blind comparison of cream containing miconazole and hydrocortisone with hydrocortisone alone in the treatment of intertrigo. A cost consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis. REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol Abnormal uterine bleeding in pre-menopausal women. Guidelines for assessing postnatal problems: introducing evidence-based guidelines in Australian general practice. Safety of weightlifting among women with or at risk for breast cancer-related lymphedema: musculoskeletal injuries and health care use in a weightlifting rehabilitation trial. Qualitative process evaluation of a problem-solving guided self-help manual for family carers of young people with first-episode psychosis Individualizing nighttime incontinence care in nursing home residents. Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol Cardiac arrest and resuscitation: an opportunity to align research prioritization and public health need.
Introduction In 2008 , the UK National Osteoporosis Guideline Group ( NOGG ) produced a guideline on the prevention and treatment of osteoporosis , with an up date in 2013 . This paper presents a major up date of the guideline , the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over . Methods Where available , systematic review s , meta-analyses and r and omised controlled trials were used to provide the evidence base . Conclusions and recommendations were systematic ally grade d according to the strength of the available evidence . Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis , fracture-risk assessment , lifestyle measures and pharmacological interventions , duration and monitoring of bisphosphonate therapy , glucocorticoid-induced osteoporosis , osteoporosis in men , postfracture care and intervention thresholds . Conclusion The guideline , which has received accreditation from the National Institute of Health and Care Excellence ( NICE ) , provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management This study examined the  emergency nurse practitioner c and i date ( ENPC ) scope of practice in a Victorian emergency department ( ED ) . The emergency nurse practitioner ( ENP ) role is relatively new in Victoria and the scope of the ENP(C ) practice is yet to be defined . International research literature regarding the ENP role has focused on outcomes such as patient satisfaction , waiting times and /or ED length of stay , accuracy and adequacy of documentation , use of radiography , and patient education , health promotion and communication issues . A prospect i ve exploratory design was used to conduct this cohort study . There were 476 ENPC-managed patients between 14 July 2004 and 31 March 2005 with an average age of 29 years . The majority ( 77.2 % ) of ENPC-managed patients were discharged from the ED . The majority of the ENPC time was devoted to clinical practice ( 55 % ) and development of clinical practice guidelines ( 25 % ) . Of patients managed by the ENPC , 49.6 % required medications , 51 % required diagnostic imaging and 8.6 % required pathology testing during their ED stay . The most common discharge referrals were made to local medical officers ( 73.5 % ) and the most common referrals made for patients requiring admission were made to the plastic surgery ( 37.3 % ) and orthopaedic ( 35.5 % ) units . Extensions to the current scope of emergency nursing practice are pivotal to effective management of specific patient groups by ENP . The ENP model of care is an important strategy for the management of increased service dem and s in Victoria ; however , little is known about the scope of the ENPC practice and many outcomes of the ENP care are yet to be defined . Further research to better underst and the relationships between ENP outcomes is required if the contribution that ENPs make to emergency care is to be accurately quantified Effective communication is widely regarded as a crucial component of patient care that can determine patient satisfaction , compliance and recovery . The plethora of communication skills training programmes available to health professionals is also a testament to the importance of this element of care . However a review of studies evaluating the effectiveness of such training programmes concluded that little behavioural change in health professionals ' communication skills was evident . This paper reports the findings of a programme offered to cancer/palliative care nurses ( n=108 ) via eight condensed three-day workshops  at various UK venues . Behavioural change was assessed through evaluation of audiotaped nursing assessment s made pre- and six weeks post-course , scored along nine previously identified key communication areas . Mean overall scores rose by 6 points ( p<0.001 ) to 20 ( out of 27 ) with statistically significant improvements on eight of the nine individual areas . Improvements in subjective levels of confidence in the areas of communication found difficult pre-course were observed immediately post-course ( p<0.001 ) and were still evident six weeks later . Similar improvements immediately post-course for teaching communication skills to colleagues ( p<0.001 ) were further improved six weeks post-course for seven of the eight areas assessed . These results suggest that three-day training courses can lead to clinical ly relevant behavioural change and improvements in perceived confidence in communication and dissemination of skills Up date d international guidelines published in 2006 have broadened the scope for the use of granulocyte colony-stimulating factor ( G-CSF ) in supporting delivery of myelosuppressive chemotherapy . G-CSF prophylaxis is now recommended when the overall risk of febrile neutropenia ( FN ) due to regimen and individual patient factors is ≥20 % , for supporting dose-dense and dose-intense chemotherapy and to help maintain dose density where dose reductions have been shown to compromise outcomes . Indeed , there is now a large body of evidence for the efficacy of G-CSFs in supporting dose-dense chemotherapy . Predictive tools that can help target those patients who are most at risk of FN are now becoming available . Recent analyses have shown that , by reducing the risk of FN and chemotherapy dose delays and reductions , G-CSF prophylaxis can potentially enhance survival benefits in patients receiving chemotherapy in curative setting s. Accumulating data from ‘ real-world ’ clinical practice setting s indicate that patients often receive abbreviated courses of daily G-CSF  and consequently obtain a reduced level of FN protection . A single dose of PEGylated G-CSF ( pegfilgrastim ) may provide a more effective , as well as a more convenient , alternative to daily G-CSF . Prospect i ve studies are needed to vali date the importance of delivering the full dose intensity of st and ard chemotherapy regimens , with G-CSF support where appropriate , across a range of setting s. These studies should also incorporate prospect i ve evaluation of risk stratification for neutropenia and its complications Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals . The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism . The mission of SCCM is to secure the highest quality care for all critically ill and injured patients . Guideline Limitations : These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who , in developing such guidelines , have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy . However , practice guidelines are not intended as absolute requirements . The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival . The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines . The guidelines offer basic recommendations that are supported by review and analysis of the current literature , other national and international guidelines , and a blend of expert opinion and clinical practicality . The population of critically ill patients in an intensive care unit ( ICU ) is not homogeneous . Many of the studies on which the guidelines are based are limited by sample size , patient heterogeneity , variability in disease severity , lack of baseline nutritional status , and insufficient statistical power for analysis . Periodic Guideline Review and Up date : This particular report is an up date and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 ( 1 ) . Governing bodies of both A.S.P.E.N. and SCCM have m and ated that these guidelines be up date d every three to five years . The data base of r and omized controlled trials ( RCTs ) that served as the platform for the analysis of the literature was assembled in a joint “ harmonization process ” with the Canadian Clinical Guidelines group . Once completed , each group operated separately in their interpretation of the studies and derivation of guideline recommendations ( 2 ) . The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature search es by the authors through December 31 , 2013 . Although the committee was aware of l and mark studies published after this date , these data were not included in this manuscript . The process by which the literature was evaluated necessitated a common end date for the search review . Adding a last-minute l and mark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript . Target Patient Population for Guideline : The target of these guidelines is intended to be the adult ( ≥ 18 years ) critically ill patient expected to require a length of stay ( LOS ) greater than 2 or 3 days in a medical ICU ( MICU ) or surgical ICU ( SICU ) . The current guidelines were exp and ed to include a number of additional subsets of patients who met the above criteria , but were not included in the previous 2009 guidelines . Specific patient population s addressed by these exp and ed and up date d guidelines include organ failure ( pulmonary , renal , and liver ) , acute pancreatitis , surgical subsets ( trauma , traumatic brain injury [ TBI ] , open abdomen [ OA ] , and burns ) , sepsis , postoperative major surgery , chronic critically ill , and critically ill obese . These guidelines are directed toward generalized patient population s but , like any other management strategy in the ICU , nutrition therapy should be tailored to the individual patient . Target Audience : The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill , primarily physicians , nurses , dietitians , and pharmacists . Methodology : The authors compiled clinical questions reflecting key management issues in nutrition therapy . A committee of multidisciplinary experts in clinical nutrition composed of physicians , nurses , pharmacists , and dietitians was jointly convened by the two societies BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms HighlightsAttitudes among nurses toward h and hygiene and h and rubbing with alcohol‐based h and rub are positive . Self‐reported alcohol‐based h and rub use is suboptimal . New graduate nurses report greater compliance with h and rubbing than more experienced nurses . Barriers to using alcohol‐based h and rub are improved in recent years . Existing barriers reported include skin sensitivity , skin damage , intolerance , and time . Background : H and hygiene reduces health care – associated infections significantly . However , international evidence suggests that practice s are suboptimal . The objective of this study was to compare and contrast h and hygiene attitudes and practice s and alcohol‐based h and rub ( ABHR ) use among nurses between 2007 and 2015 . Methods : In 2007 , a r and om sample of nurses in a large teaching hospital was invited to complete a postal survey using a vali date d question naire . In 2015 , the study was replicated among all nurses employed in a university hospital group , including the setting of the original study . Data were analyzed quantitatively and qualitatively using appropriate software . Results : Attitudes to h and hygiene were positive and > 90 % of respondents ' self‐reported compliance before and after patient contact . However , 13 % fewer in 2015 ( 42 % ) reported using ABHR  > 90 % of the time compared with in 2007 ( 55 % ) . Of nurses with < 2 years ' experience , 90 % reported using ABHR  > 50 % of the time compared with 73 % of nurses with 2‐5 years ' experience  . Barriers to ABHR  improved , but remained high ( skin sensitivity : 2007 : 23 % , 2015 : 17 % ; skin damage : 2007 : 18 % , 2015 : 13 % ; poor user acceptability and tolerance : 2007 and 2015 : 25 % ) . Conclusions : Use of positive role models , the adoption of a positive social and cultural norm within the organization , and the provision of continuing professional development opportunities may prove useful strategies in harnessing good practice among graduate nurses and in preventing negative socialization from occurring Background Patients in hospitals and nursing homes are at risk of the development of , often preventable , adverse events ( AEs ) , which threaten patient safety . Guidelines for prevention of many types of AEs are available , however , compliance with these guidelines appears to be lacking . Besides general barriers that inhibit implementation , this non-compliance is associated with the large number of guidelines competing for attention . As implementation of a guideline is time-consuming , it is difficult for organisations to implement all available guidelines . Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable , unambiguous system for implementation . A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety . The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes . This paper reports the design of this study . Methods and design The patient safety program addresses three AEs : pressure ulcers , falls and urinary tract infections . It consists of bundles and outcome and process indicators based on the existing evidence based guidelines . In addition it includes a multifaceted tailored implementation strategy : education , patient involvement , and a computerized registration and feedback system . The patient safety program was tested in a cluster r and omised trial on ten hospital wards and ten nursing home wards . The baseline period was three months followed by the implementation of the patient safety program for fourteen months . Subsequently the follow-up period was nine months . Primary outcome measure was the incidence of AEs on every ward . Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics . R and omisation took place on ward level . The results will be analysed separately for hospitals and nursing homes . Discussion Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program . Trial registration Trial registration : Clinical Trials.gov ID [ NCT00365430 The clinical guideline on the prevention of  venous thromboembolism ( VTE ) applicable to all hospital patients was published by the National Institute for Health and Clinical Excellence ( NICE ) in January 20101 with considerable media attention . We believe that adherence to this guidance will save lives that might otherwise be lost due to preventable pulmonary embolism ( PE ) . After the guideline launch , NICE and the Chair of Guideline Development Group ( GDG ) received many e-mails from doctors and members of the public including everything from extremely well-argued and robust challenges , through common misconceptions , to highly individualized personal perspectives . We are prompted by some recurring themes , or what might be called ‘ frequently asked questions ’ , to address some of these issues . The clinical guideline recommends that the first step is that all patients should be assessed at or before hospital admission . This involves a ‘ checklist ’ . The checklist approach has been found to save lives when applied to surgical operations2 and yet it is met with resistance and scorn by some doctors.3 Who would be impressed to discover that the airline pilot had skipped the preflight checklist because he found it a bore ? There is safety for the majority in a checklist – otherwise , while concentrating , quite rightly , on the immediate clinical problems of the particular medical admission or surgical operation we might forget important elements of the background safety drills . In the case of hospital-acquired VTE and its prevention , the checklist has been developed in collaboration between GDG and the Chief Medical Officer 's Working Group and will be implemented with the backing of the Department of Health . The checklist is design ed to be inclusive so that opting out of VTE prophlyaxis should be a conscious decision . Any tick against VTE risk prompts reference to the NICE clinical guideline . Some of our e-mails came from doctors who describe a patient in whom slavish adherence to guidelines would seem to them illogical . A guideline is there to guide not dictate ; it can not be made to fit 100 % of situations . Finding a loophole in the guideline does not discredit it in its entirety . The checklist should be implemented in 100 % of admissions but clinical exclusion result ing in , for example , 90 % compliance might well be about right . Health professionals should use good sense and clinical judgement in applying guidance to individual patients – but be prepared to defend a decision not to follow it . A problem with clinical judgement is that a recent memorable disaster tips the balance . Powerful evidence for this effect was found in the not dissimilar clinical question of anticoagulation of patients in atrial fibrillation to reduce the risk of stroke.4,5 If one of their patients had a bleed , doctors were less likely to prescribe anticoagulants in subsequent patients ; a single event in their recent experience weighed more heavily than the total published evidence . But perhaps worse , if an untreated patient had a stroke , no alteration in practice occurred . So , altering practice on the basis of experience is not even-h and ed : errors of commission weigh more heavily than errors of omission . The background to the VTE guidance is the reported common failure to prevent death due to PE.6 VTE prophylaxis with anticoagulants is not 100 % effective and is not 100 % safe . That is why all risks are carefully considered by the GDG and their consequences weighed in terms of QALYs lost and gained . The guideline attempts to find the nadir of risk for all our patients rather than the individual comfort zone of doctors . We have been asked specifically why we did not include children with inflammatory bowel disease , patients with cancer on the waiting list , and why a relative 's life was not saved after admission to hospital with a PE . Our answer to all of these questions , and many others like them is that they are outside our ‘ scope ’ . The frame or boundaries within which we offer guidance are determined at the beginning of the process and governs the search for evidence which may include many thous and s of papers , and after exclusion of many in the case of VTE , over 400 r and omized controlled trials ( RCTs ) remained for analysis . Each of these was critically appraised and meta-analysed and health economic models constructed for the particular setting . So the apparently simple matters of defining a hospital admission and how to categorize a day-case have to be agreed by the GDG . Others might have made other choices but the decisions were not reached without much deliberation . There are other working decisions that had to be made at the outset . If you come into hospital for the common elective operations such as cholecystectomy or hip replacement , a PE is the most likely thing to kill you . Are we entitled to use risk reductions from RCTs where the outcome was asymptomatic DVT to inform strategies to reduce deaths due to PE ? If not , we severely curtail the evidence base . Fatal PE occurs at a statistically low rate and trials powered with PE as an endpoint would require many tens of thous and s of patients . A form of common cause hypothesis7 is generally agreed for VTE and has been the premise of teaching and practice for years ( Figure1 ) . Thus , asymptomatic DVT , PE , and death due to PE event rates have a reasonably stable ratio one to another . Does this always apply ? Does it apply to knee surgery for instance ? It is arguable that local surgical causes may increase the rate for detectable DVT in knee surgery which do not share a common cause with fatal PE and then the ratio breaks down . The question can only be resolved by gaining and interpreting the evidence . We may need more . Figure 1 There is generally accepted to be a continuum between  asymptomatic DVT and fatal PE  , with a common underlying pathological cause . We have used Heinrich 's triangle to illustrate this . If the commoner events at the triangle 's base are reduced then there ... Not all setting s have been studied . The largest part of the evidence is in surgical patients and most of that is in general surgery and orthopaedics . An ENT surgeon correctly points out that there is no direct evidence that applies to his practice . But there are biological triggers related to surgery and the degree of reduced mobility entailed for its performance and recovery which have a degree of commonality . Either the GDG generalizes the available evidence on VTE risk and its modification , or offers no guidance at all for a very large number of patients having operations for which evidence was not specifically acquired . A doctor can still make a clinical judgement to deviate from guidance for an individual patient , but it would be wise to document this decision , with the reason . Extrapolation from one setting to another is itself a judgement . In one instance , the GDG had to modify guidance at the 11th hour when faced with new evidence in the use of graduated compression stockings . The existing evidence was that stockings reduced risk of VTE by about 50 % based on studies in surgical patients . Furthermore , mechanical methods are without risk of bleeding and so their use seemed a reasonable first resort in patients for whom there is clinical concern about even a small bleeding risk , such those with stroke . Then the CLOTS study reported that in patients admitted with stroke , there was no reduction in VTE risk with thigh-length stockings versus no stockings and a small but definite burden of harm related to skin pressure.8 In the face of this direct evidence against them , we could not recommend stockings for patients with stroke . But what did this evidence do for other extrapolations ? Should the new CLOTS evidence be applied in non-stroke medical patients or should we use the evidence gained in surgical patients ? This was not straightforward and was discussed at length by the GDG and a consensus reached . We wonder what others would have done ? There are other gaps in direct evidence . More recently introduced drugs have never been examined in a placebo-controlled trial . In RCTs they have been compared with the best existing drugs . To overcome this limitation , an ingenious and mathematically sophisticated method of incorporating all RCT evidence and without breaking r and omization has been developed , called network meta- analysis ( Figure 2).9 Readers of guidance should be mindful of the amount of work and level of sophistication that goes into NICE guideline development , particularly if the guidance is at odds with their previous practice . The opinions of individual doctors on a case-by-case basis are not a satisfactory way of preventing VTE . It is not possible to compute , on the basis of experience , the relative numerical risks of VTE versus bleeding ; both events occur too infrequently and there are too many other variables . Furthermore , decisions made on the basis of experience respond to recent events and discount remote events . It is a clinical question for which the NICE method of careful evaluation of all available evidence is at its most useful and we believe has clear advantages over known alternatives . Figure 2 General surgery : outcome DVT . Network meta- analysis constructed so that indirect comparisons can be made . For example fondaparinux was only compared with the then ‘ best ’ existing agent , low molecular weight heparin . VKA : vitamin K antagonists ; OBJECTIVE The present study aim ed to evaluate the knowledge and practice s of public-sector primary -care health professionals and final-year students regarding the role of  nutrition , physical activity and smoking cessation ( lifestyle modification ) in the management of chronic diseases of lifestyle within the public health-care sector . DESIGN A comparative cross-sectional descriptive quantitative study was conducted in thirty primary health-care facilities and four tertiary institutions offering medical and /or nursing programmes in Cape Town in the Western Cape Metropole . Stratified r and om sampling , based on geographical location , was used to select the health facilities while convenience sampling was used to select students at the tertiary institutions . A vali date d self-administered knowledge test was used to obtain data from the health professionals . RESULTS Differential lifestyle modification knowledge exists among both health professionals and students , with less than 10 % achieving the desired scores of 80 % or higher . The majority of health professionals seem to be promoting the theoretical concepts of lifestyle modification but experience difficulty in providing practical advice to patients . Of the health professionals evaluated , doctors appeared to have the best knowledge of lifestyle modification . Lack of time , lack of patient adherence and language barriers were given as the main barriers to providing lifestyle counselling . CONCLUSIONS The undergraduate curricula of medical and nursing students should include sufficient training on lifestyle modification , particularly practical advice on diet , physical activity and smoking cessation . Health professionals working at primary health-care facilities should be up date d by providing lifestyle modification education as part of continuing medical education Background Chronic obstructive pulmonary disease ( COPD ) is a significant health problem worldwide . This r and omised controlled trial aims at testing a new approach that involves a registered nurse working in partnership with patients , general practitioners ( GPs ) and other health professionals to provide care to patients according to the evidence -based clinical practice guidelines . The aim is to determine the impact of this partnership on the quality of care and patient outcomes . Methods A cluster r and omised control trial design was chosen for this study . R and omisation occurred at practice level . GPs practising in South Western Sydney , Australia and their COPD patients were recruited for the study .The intervention was implemented by nurses specifically recruited and trained for this study . Nurses , working in partnership with GPs , developed care plans for patients based on the Australian COPD X guidelines . The aim was to optimise patient management , improve function , prevent deterioration and enhance patient knowledge and skills .  Control group patients received ' usual ' care from their GPs . Data collection includes patient demographic profiles and their co-morbidities . Spirometry  is being performed to assess patients ' COPD status and CO analyser to vali date their smoking status . Patients ' quality of life and overall health status are being measured by St George 's Respiratory Question naire and SF-12 respectively . Other patient measures being recorded include health service use , immunisation status , and knowledge of COPD . Qualitative methods will be used to explore participants ' satisfaction with the intervention and their opinion about the value of the partnership . Analysis Analysis will be by intention to treat . Intra-cluster ( practice ) correlation coefficients will be determined and published for all primary outcome variables to assist future research . The effect of the intervention on outcomes measured on a continuous scale will be estimated and tested using mixed model analysis of variance in which time and treatment group will be fixed effects and GP practice and subject nested within practice will be r and om effects . The effect of the intervention on the dichotomous variables ( such as smoking status , patient knowledge ) will be analysed using generalised estimating equations with a logistic link and a model structure that is analogous to that described above . Trial registration Background and aims : Lack of compliance on the part of old participants has been reported in several r and omised nutritional intervention studies . However , lack of compliance by staff may also have a significant impact on the effect of interventions . The aim of this paper is to test the hypothesis that , in an intervention study with focus on nutrition , exercise and oral care in old nursing home residents , lack of compliance by staff rather than residents is the major problem . Methods : An eleven week r and omized , controlled trial in seven nursing homes , with nutrition , exercise and oral care strategies , and 62 residents in the intervention group .  Staff and research ers documented compliance of residents with the various strategies , including notes about problems . Results : The nutrition and exercise strategies  were well accepted by participating residents . The main reason for non-compliance may be related to staff problems . Up to one-sixth of the planned nutrition interventions were not documented as having been given to the residents . Conclusions : Lack of compliance by staff rather than residents seemed to be the main problem . In order to improve compliance in future studies , more focus should be put on the effect of practical implementation on staff . Insight into these matters may give valuable information to counteract staff problems , facilitate implementation in long term , and hence improve the benefits of nutrition interventions A double-blind comparative study between 1 % hydrocortisone cream and a combination of 1 % hydrocortisone cream and 2 % miconazole cream has highlighted some of the problems with this type of research in general practice . The collection of adequate patient numbers within a predefined time scale proved a major problem . However , the study demonstrated the safety and efficacy of both these preparations in the treatment of intertrigo BACKGROUND The practice nurse is central to the development of a primary care-led National Health Service . Skin diseases can have a major impact on patients ' lives but general practitioners ( GPs ) lack many of the skills of practical dermatology care and support . AIM To determine whether a primary care dermatology liaison nurse should be introduced by our health authority . We identified the re sources consumed and the benefits that accrued from a practice nurse who had received training in practical dermatology care . METHOD A cost consequence study in parallel with a r and omised controlled trial was undertaken in a group of nine GPs and 109 patients between the ages of 18 and 65 years who had a diagnosis of psoriasis or eczema . RESULTS Although there was a significant improvement in our primary outcome measure within group , when compared with the control group significance was not achieved . There was no significant change in the Euroqol measure but the clinical instrument showed a significant change when compared with control . On entry , our qualitative data identified three main themes -- the embarrassment caused by these skin conditions , the wish for a cure rather than treatment , and concern over the long-term effects of steroids . On completion , 20 % of patients expressed that they had received a positive benefit from the clinic . CONCLUSION This study demonstrates the difficulties of obtaining relevant information to facilitate decisions on how re sources should be allocated in primary care . Not all questions can be answered by large multi-centred trials and studies themselves have an opportunity cost consuming re sources that could otherwise be spent on direct health care . Often , local re source decisions will be based on partial evidence -yielding solutions that are satisfactory rather than optimum but which are , nevertheless , better than decisions taken with no evidence at all Background The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international setting s with negative consequences particularly for migrants . This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice . In this paper , we describe our use of a contemporary social theory , Normalization Process Theory and participatory research methodology —Participatory Learning and Action — to investigate and support implementation of such guidelines and training initiatives in routine practice . Methods This is a qualitative case study , using multiple primary care sites across Europe . Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders — migrant service users , general practitioners , primary care nurses , practice managers and administrative staff , interpreters , cultural mediators , service planners , and policy makers . We are conducting a mapping exercise to identify relevant guidelines and training initiatives . We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory ’s four constructs — coherence , cognitive participation , collective action , and reflexive monitoring . Through this , we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting . We will prospect ively investigate and support the implementation journeys for the five selected interventions . Data will be generated using a Participatory Learning and Action approach to interviews and focus groups . Data analysis will follow the principles of thematic analysis , will occur in iterative cycles throughout the project and will involve participatory co- analysis with key stakeholders to enhance the authenticity and veracity of findings . Discussion This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action , which will provide a novel approach to the analysis of implementation journeys . The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and method ological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes BACKGROUND Abnormal uterine bleeding is the direct cause of a significant health care burden for women , their families , and society as a whole . Up to 30 % of women will seek medical assistance for this problem during their reproductive years . This guideline replaces previous clinical guidelines on the topic and is aim ed to enable health care providers with the tools to provide the latest evidence -based care in the diagnosis and the medical and surgical management of this common problem . OBJECTIVE To provide current evidence -based guidelines for the diagnosis and management of  abnormal uterine bleeding ( AUB ) among women of reproductive age . OUTCOMES Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB . METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada , type of practice , subspecialty expertise , and general gynaecology background . The committee review ed relevant evidence in the English medical literature including published guidelines . Recommendations were established as consensus statements . The final document was review ed and approved by the Executive and Council of the SOGC . RESULTS This document provides a summary of up-to- date evidence regarding diagnosis , investigations , and medical and surgical management of AUB . The result ing recommendations may be adapted by individual health care workers when serving women with this condition . CONCLUSIONS Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age . St and ardization of related terminology , a systematic approach to diagnosis and investigation , and a step-wise approach to intervention is necessary . Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions . EVIDENCE Published literature was retrieved through search es of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary ( e.g. uterine hemorrhage , menorrhagia ) and key words ( e.g. menorrhagia , heavy menstrual bleeding , abnormal uterine bleeding ) . Results were restricted to systematic review s , r and omized control trials/controlled clinical trials , and observational studies written in English and published from January 1999 to March 2011 . Search es were up date d on a regular basis and incorporated in the guideline to February 2013 . Grey ( unpublished ) literature was identified through search ing the websites of health technology assessment and health technology-related agencies , clinical practice guideline collection s , clinical trial registries , and national and international medical specialty societies . VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care ( Table ) . BENEFITS , HARMS , AND COSTS Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding , their families , and society . The economic cost of implementing these guidelines in the Canadian health care system was not considered BACKGROUND Postnatal morbidity is high , and many GPs lack the confidence and knowledge to deal with common postnatal problems . There is a high consultation rate , but few women disclose common health problems . OBJECTIVE The aim of the present study was to increase the knowledge and skills of GPs to enable them to identify and manage common health problems experienced by women in the year following childbirth . METHODS An educational programme [ Guidelines for Assessing Postnatal Problems ( GAPP ) ] embedded within a large r and omized community intervention trial [ Program of Re sources , Information and Support for Mothers ( PRISM ) ] with a before/after evaluation was undergone by Australian GPs working in four metropolitan and four rural communities . The programme comprised audit , interactive workshops , role-play and evidence -based guidelines , and was evaluated at baseline and 6 months through written question naires and a surgery consultation with a trained simulated patient evaluator . RESULTS A total of 68 ( 86 % ) GPs took part in the full GAPP programme . The odds of a GP improving on the knowledge items ranged from 1.0 to 16 , with the greatest change occurring in knowledge about the effectiveness of cognitive behavioural therapy for maternal depression . Of the GPs with an incorrect response at baseline , the percentage demonstrating improved knowledge at follow-up ranged from 22 to 100 % . Around half of the GPs demonstrated excellent communication skills at baseline . Of the remaining GPs , more than half demonstrated greatly improved skills to detect common postnatal problems at follow-up . At baseline simulated patient visit , 70 % of GPs inquired about sexual problems yet none inquired about the possibility of abuse , whereas at follow-up 94 % inquired about sexual problems and 51.5 % facilitated the disclosure of physical and emotional abuse . Anonymous feedback on the programme by participating GPs showed that 89 % believed the programme positively influenced their actual practice . Interestingly , GPs demonstrated greater knowledge and skills in the simulated setting than on the written question naire . CONCLUSIONS This relatively brief multifaceted educational programme assisted many participants in improving their knowledge and the skills required to improve both physical and emotional health after birth . Despite being experienced clinicians and participating actively in a programme on interviewing skills , half of the GPs did not facilitate disclosure of the underlying sensitive issue ( abuse ) during the follow-up consultation and could benefit from further in-depth training in effective communication skills INTRODUCTION It has been noted that only 14 % of all clinical trials are translated into practice . The objective of this paper is to promote translation of an efficacious rehabilitative exercise program for breast cancer survivors by clarifying for clinicians the safety profile of participants ( e.g. , rates of musculoskeletal injury and referral to medical professionals ) , and to use this evidence to make recommendations on the appropriate training of health and fitness staff who would be capable of safely , effectively , and sustainably delivering the program . METHODS Breast cancer survivors with and at risk for lymphedema were r and omized to twice-weekly weightlifting or st and ard care for 1 year . An injury survey and health care evaluation were administered after 1 year and in 3-month intervals , respectively . RESULTS The cumulative incidence and rate of injury were higher in the weightlifting than in the control group . The injury rates were 2.3 and 0.3 per 1,000 bouts of weightlifting among breast cancer survivors with and at risk for lymphedema , respectively . Among breast cancer survivors with or at risk for lymphedema , 20.9 % in the weightlifting group had an encounter with a health care provider that required cessation or dose modification of weightlifting . CONCLUSION Despite the demonstrated efficacy of weightlifting , musculoskeletal injuries and other health problems did occur . Therefore , for the successful translation of this rehabilitative intervention into clinical practice , health and fitness professionals working with breast cancer survivors need the knowledge , skills , and abilities that clarify their scope of practice to address these health care needs Background Caring for a young person experiencing first-episode psychosis is challenging and can affect carers ’ well-being adversely . While some face-to-face approaches have achieved promising outcomes , they are costly and re source -intensive to provide , restricting their reach and penetration . Guided self-help in book-form ( or bibliotherapy ) is an alternative but untested approach in these circumstances . In this study , we aim ed to evaluate carers ’ beliefs about the usefulness of problem-solving guided self-help manual for primary carers of young people with first-episode psychosis . Methods A qualitative process evaluation nested in a r and omised controlled trial , conducted across two early intervention psychosis services in Melbourne , Australia . 124 carers were r and omised to problem-solving guided self-help intervention or treatment as usual .  We also undertook a qualitative process evaluation , using individual interviews , with a r and om sample of 24 of the intervention group . A thematic analysis of the qualitative data was undertaken , which is the subject of this paper . Interviews were conducted between January 2009 and September 2010 . Results Three themes were abstract ed from the data , reflecting carers ’ beliefs about the usefulness of the manual : promoting carers ’ well-being , increasing carers ’ underst and ing of and support for the young person with first-episode psychosis , and accessibility and delivery modes of the programme . Conclusion This process evaluation highlights that guided self-help is useful in informing and supporting carers of affected young people . While there is scope for broadening the delivery modes , the approach is easy to use and accessible , and can be used as a cost-effective adjunct to st and ard support provided to carers , by community mental health nurses and other clinicians . Trial registration BACKGROUND Urinary incontinence is a common problem among nursing home ( NH ) residents and can be successfully treated with prompted voiding during daytime hours . A previous study of incontinent NH residents demonstrated that noise from the staff and other residents and light and noise from staff-initiated incontinence care routines were associated with waking episodes . Nighttime incontinence care should be individualized to minimize sleep disruption while considering moisture exposure that could affect skin health . Although descriptive studies have been published , there are no published intervention studies describing attempts to improve nighttime environmental factors in NHs . OBJECTIVE To individualize nighttime incontinence care while minimizing sleep disruption among NH residents . METHOD Subjects were assigned to a 2- or 4-hour incontinence care schedule based on each resident 's risk of skin problems using objective data of spontaneous body movements at night and skin health during baseline , and the research staff provided incontinence care if residents were found awake . RESULTS Awakenings due to light and sound associated with incontinence care were significantly reduced during the intervention phases ( p < .001 ) , and there were no adverse changes in skin health or on most risk factors associated with skin ( e.g. , exposure to moisture , body turns ) . CONCLUSIONS Incorporating this intervention component into more comprehensive efforts to improve sleep and evaluating the long-term effects of the intervention on skin health are recommended Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Fewer than 8 % of adult out-of-hospital cardiac arrest ( OOH-CA ) victims survive to hospital discharge despite public education of event recognition , early notification of 9 - 1 - 1 , byst and er cardiopulmonary resuscitation , automated external defibrillator ( AED ) use , therapeutic hypothermia , and improvements in emergency medical service delivery.1 Densely populated urban areas such as New York , NY , and Chicago , Ill , where a large number of cardiac arrests occur , report even lower ( 1.4 % to 2 % ) survival rates.2,3 Unlike other areas of cardiovascular health such as myocardial infa rct ion , which has demonstrated a 3-fold decrease in acute mortality,4 the improvements in outcome from OOH-CA have remained modest over the last 25 years.5 Is this dismal survival and lack of progress a result of the biological lethality of the condition , or has inadequate research been done to define its pathogenesis , pathophysiology , and prevention and the optimal implementation of effective treatments ? OOH-CA is obviously a life-threatening condition , yet it is a “ treatable disease ” in the sense that medical interventions can improve survival significantly.6,–,8 Moreover , a nearly 500 % difference in survival rates exists across communities in the United States , suggesting that variability in the quality of resuscitation care is driving large differences in community survival rates.9 Collectively , these data suggest the potential for a major improvement in community survival rates that could save tens of thous and s of lives . So where is the problem ? Improving care and survival requires a commitment to sustained , high- quality , basic scientific and clinical research . Despite the devastating public health consequences of OOH-CA , the r and omized clinical trial ( RCT ) base from which evidence -based resuscitation guidelines are derived is limited compared with that used to derive evidence -based guidelines for other cardiovascular diseases . Table 1 lists the number of MEDLINE English language citations of resuscitation RCTs compared with ST-elevation myocardial infa rct ion ,
Although most study - authors were positive , we could not draw firm conclusions about any of the pharmaceutical interventions .
Even patients that received placebo intervention showed improvement .
There is weak evidence that reduction mammaplasty may be helpful to treat inframammary intertrigo .
Conclusions There is no evidence at all about the prevention of intertrigo and there is no firm evidence about its treatment .
Background Intertrigo in the large skin folds is a common problem .
There is a plethora of treatments , but a lack of evidence about their efficacy .
A nursing guideline on this matter had to be up date d and broadened in scope to other health care professionals .