Is antibiotic prophylaxis required for flexible cystoscopy? A truncated randomized double-blind controlled trial. Due to low infection rates no routine anti‐infective prophylaxis is required in younger patients with chronic lymphocytic leukaemia during fludarabine‐based first line therapy Oral ciprofloxacin or trimethoprim reduces bacteriuria after flexible cystoscopy Pediatricians’ Attitudes and Practices on ADHD Before and After the Development of ADHD Pediatric Practice Guidelines Urinary tract infection and patient satisfaction after flexible cystoscopy and urodynamic evaluation. Use of granulocyte colony-stimulating factor (G-CSF) in patients receiving myelosuppressive chemotherapy for the treatment of cancer. Provincial Systemic Treatment Disease Site Group. The Issue of Prophylactic Antibiotics prior to Flexible Cystoscopy Antibiotic prophylaxis for cardiac surgery in Australia. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework Why fundamentals of endoscopic surgery (FES)? What is your research question? An introduction to the PICOT format for clinicians. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Utility and limits of the mini mental state examination in evaluating consent capacity in Alzheimer's disease. Improving Knowledge of General Dental Practitioners on Antibiotic Prescribing by Raising Awareness of the Faculty of General Dental Practice (UK) Guidelines Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines. Research criteria versus clinical criteria for interstitial cystitis. Adherence to international antimicrobial prophylaxis guidelines in cardiac surgery: a Jordanian study demonstrates need for quality improvement. An effectiveness trial of cognitive behaviour therapy in a representative sample of outpatients with psychosis. Improving support for family carers: Key implications for research, policy and practice Life Support for Patients without a Surrogate Decision Maker: Who Decides? A new system for grading recommendations in evidence based guidelines Reporting of long-term extension studies: lack of consistency calls for consensus
PURPOSE To examine the incidence of  urinary tract infection ( UTI ) after flexible cystoscopy ( FC ) and determine whether prophylactic norfloxacin reduces this incidence compared with placebo . PATIENTS AND METHODS A double-blind trial was performed , r and omizing 234 patients to either 400 mg of norfloxacin or placebo prior to FC . All patients provided a midstream urine specimen ( MSU ) before the procedure , as well as at day 3 and day 7 after FC . In addition , a telephone question naire was performed to correlate the nature and severity of any symptoms associated with UTI . RESULTS Interim analysis was performed because of the low recruitment rate , and a significantly lower infection rate than expected meant that the trial was discontinued . There was one symptomatic UTI in the placebo group ( 0.82 % ) and one in the norfloxacin group ( 0.89 % ) . The UTI in the placebo group was de novo , while the infection in the norfloxacin group was secondary to pre-FC bacteriuria . There was no difference in the infection rates in the two groups . The overall infection rate ( de novo and secondary to existing bacteruria ) after FC was 0.85 % . CONCLUSION Infection after flexible cystoscopy is rare and not associated with significant morbidity . A much larger study would be required to determine whether antibiotic prophylaxis significantly reduces the rate of postprocedure UTI The impact of the combination therapy fludarabine plus cyclophosphamide ( FC ) in comparison with fludarabine alone regarding the incidence and severity of infections among previously untreated patients with chronic lymphocytic leukaemia ( CLL ) was evaluated within a multicentre phase III study . A total of 375 patients , up to 65 years old , were r and omised between fludarabine or FC for first line therapy . No routine anti‐infective prophylaxis was provided . A total of 196 infectious episodes , including 33 severe infections , were documented . In the fludarabine arm , 32·9 % of the patients developed an infectious complication compared with 39·9 % in the FC arm ( P = 0·2 ) . No difference was observed in the rate of severe infections ( Common Toxicity Crtieria grade s III and IV ) between both treatment arms . Dose reductions were performed more frequently in FC‐treated patients  . Granulocyte colony‐stimulating factor ( G‐CSF ) was administered due to leucopenia in 5 % of all patients . A multivariate regression model identified only elevated thymidine kinase , but not the treatment arm , as a statistically independent risk factor for infections . In summary , FC was not associated with a higher rate of infections compared with fludarabine alone . No routine antibiotic or virostatic prophylaxis , or pre‐emptive treatment with G‐CSF , is necessary in first line therapy with fludarabine‐based regimens in younger patients with CLL , if adequate dose reduction is performed . The combination therapy FC is not associated with a higher rate of infections  compared with fludarabine alone . No routine antibiotic or virostatic prophylaxis as well as pre‐emptive treatment with G‐CSF is necessary in first line therapy with fludarabine‐based regimen in younger patients with CLL , if adequate dose reductions due to cytopenia or previous infections are performed To report a large prospect i ve , pragmatic , double‐blind r and omized controlled trial to determine whether oral prophylactic antibiotics reduce the risk of bacteriuria  after flexible cystoscopy ( FC ) , as up to 10 % of patients develop urinary infection afterwards , with significant morbidity and costs for health services Purpose : The study aims to assess the changes in attitudes and practice s about ADHD reported by AAP fellows between 1999 and 2005 during which AAP ADHD guidelines , training , and quality improvement initiatives occurred . Method : The study assesses AAP-initiated surveys  that were conducted between 1999 and 2005 and involving a r and om sample of 1,000 and 1,603 pediatricians , respectively . Results : The findings reveal that significant , although modest , increases occurred in pediatric practitioners ’ self-reported adherence to the guidelines . About 81 % of respondents reported routine use of formal diagnostic criteria ( up from 67 % ) , and 67 % of the respondents routinely use ADHD teacher rating scales ( compared to 49 % in the 1999 survey ) . Findings further reveal that treatment with stimulant medications was used extensively by pediatricians from both surveys ; more pediatricians in the 2005 survey reported use of a second stimulant if the first did not work , and still more reported almost always providing parent training , although the estimated number remained only about a quarter of the total ; and greater familiarity with the initiatives predicted better reported adherence to the guidelines . Conclusion : The reported behaviors of practitioners have moved in the direction of greater adherence with the recommended AAP ADHD guidelines , and there was a positive response to , and a greater use of , the material s developed to enhance practice . The authors infer that practice changes may be due to many factors , including AAP guidelines and associated implementation efforts . Changing physician practice s needs to be sustained through a continuing process that requires multiple , varying , sustained efforts directed at physicians , other providers , and families OBJECTIVES To investigate the incidence of symptomatic and asymptomatic bacteriuria and to assess patient satisfaction after flexible cystoscopy  ( FC ) and  urodynamic ( UD ) evaluation in a prospect i ve survey . The incidence of urinary tract infection after FC and UD studies and the use of prophylactic antibiotics are issues of debate . The tolerability and acceptance of FC and UD studies by patients have not been thoroughly documented . It would be helpful to be able to give such information to patients before performing these procedures . METHODS A total of 215 nonconsecutive patients seen as out patients for FC and UD studies to evaluate various indications were studied . A midstream urine sample was taken before and 48 hours after the procedures . Patients were given a question naire that inquired about the presence of lower urinary tract symptoms before and 48 hours after the procedures . The self-administered question naire included questions to assess patients ' tolerance of the procedures and how it compared with their expectations . RESULTS Of the 201 patients analyzed ( FC 103 , UD studies 98 ) , 9 patients ( 4 . 5 % ) developed significant bacteriuria within 48 hours of FC and UD studies . Only 2 patients with significant bacteriuria reported newly developed symptoms within 48 hours . In a subgroup of 25 patients who were given prophylactic antibiotics for various reasons , 6 ( 24 % ) reported new symptoms , although none developed significant bacteriuria . The association between patients who had preprocedure pyuria ( n = 7 ) and the development of significant growth after the procedure ( n = 6 ) was significant ( P < 0.01 ) . In response to the patient-satisfaction question naire , 166 ( 82.5 % ) reported that the procedure was not as bad as they expected , and 200 ( 99.5 % ) said that they would undergo the test again if necessary . CONCLUSIONS FC and UD studies are safe , well-tolerated procedures . The addition of prophylactic antibiotics in these procedures is unnecessary , unless specific indications are present GUIDELINE QUESTIONS 1 ) Does G-CSF reduce the incidence of important adverse clinical outcomes due to infections in patients with cancer treated with myelosuppressive therapy ? 2 ) Does G-CSF allow maintenance of the chemotherapy dose with the goal of improving survival ? OBJECTIVE To evaluate the evidence for the role of G-CSF in patients receiving myelosuppressive chemotherapy for the treatment of cancer . OUTCOMES Clinical outcomes reflecting events that may affect quality of life and /or re source utilization ( e.g. , rates and duration of hospitalization , antibiotic use ) ; outcomes reflecting the effect of treatment on infection rates , tumour response and survival and those related to the biological effect of G-CSF . PERSPECTIVE ( VALUES ) Evidence was selected , review ed and synthesized by members of the Provincial Systemic Treatment Disease Site Group ( DSG ) of the Cancer Care Ontario Practice Guidelines Initiative . Drafts of this document have been circulated and review ed by members of the Systemic Treatment DSG . The DSG comprises medical oncologists , pharmacists , supportive care personnel and administrators . Evaluation by clinicians was considered in the final practice guideline . Community representatives did not participate in the development of this report but will in future reports . Guidelines approval does require participation by community representatives . QUALITY OF EVIDENCE Two published guidelines and an up date of one guideline were identified . Ten eligible r and omized controlled trials published in English were included . BENEFITS A meta- analysis of data from 8 trials showed that the odds of experiencing febrile neutropenia with G-CSF were significantly reduced ( odds ratio 0.38 ; 95 % confidence interval [ CI ] 0.27 to 0.52 ; p < 0.00001 ) . G-CSF reduced the risk of febrile neutropenia by 34 % ( risk ratio 0.66 ; 95 % CI 0.51 to 0.86 ; p = 0.0015 ) . The use of G-CSF was associated with a significant reduction in antibiotic usage and days spent in hospital in 2 trials and had no effect in the other 4 in which it was measured . Five trials reported no difference in overall median survival , with 2 small trials detecting a significant increase related to G-CSF . However , further research is necessary to confirm these results . HARMS The toxic effects of G-CSF are relatively mild . The most consistent clinical symptom attributed to G-CSF is bone pain , reported in incidence rates ranging from 20 % to 50 % in 3 trials . Except for one case , reported bone pain was mild . PRACTICE GUIDELINE In cancer patients receiving myelosuppressive chemotherapy , granulocyte colony-stimulating factor ( G-CSF ) may be beneficial for some patients . If a reduction in the number of febrile neutropenic episodes , or in the duration of such episodes , is expected to improve quality of life , then G-CSF is a reasonable treatment option for selected patients . A clear justification for the use of G-CSF should be stated . If the objective of using G-CSF is to maintain dose intensity of antitumour agents , then G-CSF can be recommended where reduction in dose intensity has been shown in r and omized controlled trials to reduce survival or disease-free survival . Although the evidence is weaker , the Systemic Treatment DSG would support the practice endorsed by other guidelines ( American Society of Clinical Oncology , Ontario Drug Benefit Plan ) and would recommend G-CSF for patients receiving potentially curative chemotherapy : i ) as primary prophylaxis ; that is , where dose reductions below a specified level are required because of a known high risk of febrile neutropenia , or ii ) as secondary prophylaxis in patients receiving chemotherapy of established efficacy who have suffered a prior serious episode of febrile neutropenia due to the same chemotherapy regimen . The exact cut-off for dose reductions is unknown at this time and ought to be left to the judgement of the clinician . In general , the use of  G-CSF  for dose reductions lower than 20 % is not recommended . ( ABSTRACT TRUNCATED Objective : The aim of this study was to determine whether single – dose parenteral antibacterial therapy significantly alters the rate of infection in patients undergoing flexible cystourethroscopy . Patients and Methods : 162 patients were studied prospect ively having either received parenteral antibacterial chemoprophylaxis prior to flexible cystourethroscopy or not . Pre– and postprocedure mid stream sample s of urine ( MSSU ) were obtained to objective ly evaluate the presence of infection . Results : Gentamicin prophylaxis reduced the rate of post – cystoscopy – positive MSSUs from 21 to 5 % . Conclusion : The surprisingly high rate of infection after flexible cystoscopy was significantly reduced by a single dose of gentamicin OBJECTIVE To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocol s , agent selection and duration of administration . DESIGN , SETTING AND PARTICIPANTS Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia , conducted in 2004 and 2008 , using a structured telephone question naire of the attending senior intensive care clinician in each unit . MAIN OUTCOME MEASURES Existence of a protocol in the unit for antibiotic prophylaxis , specific antibiotic agents used and their duration of administration . RESULTS Between 2004 and 2008 , reported protocol use increased from 58 % to 80 % ( P = 0.02 ) , while concordance with version 13 of the Australian Therapeutic guidelines : antibiotic for both choice of agent and timing ( duration of administration ) remained around 10 % . Use of multiple agents was common , as was continued antibiotic administration after completion of surgery . Over 4 years , the proportion of cardiac surgical units reporting  vancomycin administration  for routine valve surgery prophylaxis doubled to 62 % ( P < 0.001 ) . CONCLUSION Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery , concordance with national antibiotic guidelines remained low , with duration of antibiotic administration deviating most from recommendations . Prophylactic  vancomycin  use appears to have increased substantially in recent years . Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospect i ve r and omised study or st and ardised national surveillance of cardiac surgical site infection rates BACKGROUND In 2010 , the Canadian Thoracic Society ( CTS ) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older , and adults , including an up date d Asthma Management Continuum . The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline up date process , focusing , in this first iteration , on topics of controversy and ⁄or gaps in the previous guidelines . METHODS Four clinical questions were identified as a focus for the up date d guideline : the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy ; the initiation of adjunct therapy to inhaled corticosteroids ( ICS ) for uncontrolled asthma ; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever , and as a reliever and a controller ; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan . The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics . In addition , literature search es were performed to identify relevant systematic review s and r and omized controlled trials . The panel formally assessed and grade d the evidence , and made 34 recommendations . RESULTS The up date d guideline recommendations outline a role for inclusion of assessment of sputum eosinophils , in addition to st and ard measures of asthma control , to guide adjustment of controller therapy in adults with moderate to severe asthma . Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations . New recommendations for the adjustment of controller medication within written action plans are provided . Finally , priority areas for future research were identified . CONCLUSIONS The present clinical practice guideline is the first up date of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee 's new guideline development process . Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide up date s reflecting new evidence Background Dementia is a growing problem , causing substantial burden for patients , their families , and society . General practitioners ( GPs ) play an important role in diagnosing and managing dementia ; however , there are gaps between recommended and current practice . The aim of this study was to explore GPs ’ reported practice in diagnosing and managing dementia and to describe , in theoretical terms , the proposed explanations for practice that was and was not consistent with evidence -based guidelines . Methods Semi-structured interviews were conducted with GPs in Victoria , Australia . The Theoretical Domains Framework ( TDF ) guided data collection and analysis . Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours . Data were analysed using content and thematic analysis . This paper presents an in-depth description of the factors influencing two behaviours , assessing co-morbid depression using a vali date d tool , and conducting a formal cognitive assessment using a vali date d scale . Results A total of 30 GPs were interviewed . Most GPs reported that they did not assess for co-morbid depression using a vali date d tool as per recommended guidance . Barriers included the belief that depression can be adequately assessed using general clinical indicators and that vali date d tools provide little additional information ( theoretical domain of ‘ Beliefs about consequences ’ ) ; discomfort in using vali date d tools ( ‘ Emotion ’ ) , possibly due to limited training and confidence ( ‘ Skills ’ ; ‘ Beliefs about capabilities ’ ) ; limited awareness of the need for , and forgetting to conduct , a depression assessment ( ‘ Knowledge ’ ; ‘ Memory , attention and decision processes ’ ) . Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a vali date d scale be undertaken . Key factors enabling this were having an awareness of the need to conduct a cognitive assessment ( ‘ Knowledge ’ ) ; possessing the necessary skills and confidence ( ‘ Skills ’ ; ‘ Beliefs about capabilities ’ ) ; and having adequate time and re sources ( ‘ Environmental context and re sources ’ ) . Conclusions This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline -recommended diagnosis and management of dementia in general practice . It has identified key factors likely to explain GPs ’ uptake of the guidelines . The results have informed the design of an intervention aim ed at supporting practice change in line with dementia guidelines , which is currently being evaluated in a cluster r and omised trial As flexible endoscopy has moved into the mainstream , gastroenterologists have embraced many of the skills and techniques particular to this modality of diagnosis and intervention . Their adoption of flexible endoscopic technology and training , and the lack of enthusiasm for endoscopic therapy potentials by surgeons , has left many surgical residents and practicing surgeons deficient in endoscopic skills . As a result , education of surgical residents in flexible endoscopy  has lagged and training of surgical residents in flexible endoscopy  is increasingly coming under scrutiny and has become an area of debate . The medical literature and practice guidelines are replete with articles from surgeons and gastroenterologists debating the appropriate education and training in flexible endoscopy . Both surgical and gastroenterology professional societies have published guidelines for training in flexible endoscopy . These guidelines are often at odds with each other , citing opposing literature supporting their position on appropriate criteria for training in basic upper and lower endoscopy [ 1–4 ] . Flexible endoscopy is a critical element of any general surgeon ’s and colorectal surgeon ’s practice . In 2007 , 74 % of rural surgeons performed more than 50 flexible endoscopic procedures each year , with 42 % of rural surgeons performing more than 200 flexible endoscopic procedures annually [ 5 ] . In a 2010 report on rural , under-served areas that lack gastroenterology services , 39.8 % of an American general surgeons ’ practice comprises flexible endoscopic procedures [ 6 ] . In Canada , surgeons were found to be the primary providers of flexible endoscopic services in smaller urban and rural areas [ 7 ] . The American Board of Surgery ( ABS ) has begun to address the training inequity that exists between general surgery residents and gastroenterology fellows [ 8 ] . In an effort to ensure surgical residents are fully trained and competent in flexible endoscopy , the ABS has not only increased the minimum requirements for training general surgery residents in flexible endoscopy but has also undertaken the task of formalizing a flexible endoscopy curriculum for its residents . Currently , the ABS and Residency Review Committee ( RRC ) recommend 35 upper endoscopic procedures and 50 colonoscopies as the minimum number of procedures to be performed by surgical residents . The Society of American Gastrointestinal and Endoscopic Surgeons ( SAGES ) and the ABS have long espoused that numbers do not ensure competency in surgical or endoscopic procedures . This position is fully supported by data . In 2004 , the SAGES esophagogastroduodenoscopy ( EGD ) Outcomes Study Group prospect ively review ed 3,525 EGDs performed by surgeons , showing a high degree of success with low morbidity . There was no correlation between experience ( i.e. number of cases performed ) and completion rates or major complications [ 9 ] . A similar trial by the SAGES Colonoscopy Study Outcomes Group prospect ively review ed 13,580 colonoscopies performed by surgeons and found no correlation between experience and complications , with an acceptable success rate . The investigators noted that a minimum of 50 colonoscopies with 100 performed annually showed a significant improvement in completion rates Taskforce Members are listed in Appendix Clinicians often witness impressive treatment results in practice and may wish to pursue research to formally explore their anecdotal experiences . The potential to further new knowledge both within the profession and to the greater healthcare system is compelling . An obvious next step for a practitioner considering research is to connect with experienced research ers to convey their idea for a study , who may in turn ask , “ What is your research question ? ” With limited underst and ing of how to respond , this interaction may result in the first and last experience these clinicians will have with the research community . It has been estimated that between 1 % and 7 % of the chiropractic profession in Canada is engaged in research . 1,2 Arguably , this low engagement could be the result of practitioners ’ perceived importance of research and levels of research literacy and capacity . However , increasing dem and s for evidence -based approaches across the health system puts pressure on all clinicians to base their decisions on the best available scientific evidence . Lack of clinician representation in research has the probable effect of limiting growth and new developments for the profession . Furthermore , lack of clinician involvement in research complicates the transfer of study findings into practical setting s. The Canadian Institutes of Health Research describes integrated knowledge translation as a process that involves collaboration between research ers and knowledge users at all stages of a research project.3 This necessitates involvement of clinicians to help in forming a research question , interpreting the results , and moving research findings into practice . This shared effort between clinicians and research ers increases the likelihood that research initiatives will be relevant to practice .3 Conversely , it has been reported that there is a growing communication gap between clinicians and academics in chiropractic . 4 Clinicians have important practice -related questions to ask , but many may lack the ability to map out their research strategy , specifically in communicating their question in a manner required to develop a research protocol . David L. Sackett , Officer of the Order of Canada and the founding Chair of Canada ’s first Department of Clinical Epidemiology & Biostatistics at McMaster University , highlights the importance of mapping one ’s research strategy in exploration of the research question : “ one-third of a trial ’s time between the germ of your idea and its publication in the New Engl and Journal of Medicine should be spent fighting about the research question . ” ( personal communication , November 30 , 2011 ) We describe a r and omized controlled trial ( RCT ) example to highlight how clinicians may use existing literature and the PICOT format to formulate a research question on treatment efficacy OBJECTIVE To determine the effect of continuing medical education ( CME ) with and without a quality assurance component ( CME+QA ) on physician practice s in the prevention of venous thromboembolism . METHODS A communitywide study was performed in 15 short-stay hospitals in central Massachusetts . The study population included 3158 patients in acute-care hospitals with multiple risk factors for venous thromboembolism . Study hospitals were r and omly assigned to one of two educational strategies or to a control group that received no intervention . RESULTS The proportion of patients at high risk for venous thromboembolism who received effective methods of prophylaxis increased significantly from 29 % in 1986 to 52 % in 1989 ( P < .001 ) . This increase was seen in all study groups : control hospitals , 40 % to 51 % ( P < .001 ) ; CME hospitals , 21 % to 49 % ( P < .0001 ) ; and CME+QA hospitals , 27 % to 55 % ( P < .0001 ) . The increase in prophylaxis use from 1986 to 1989 was significantly greater among patients cared for in hospitals whose physicians participated in a formal CME program ( an increase of 28 % ) than in control hospitals ( an increase of 11 % ) ( P < .001 ) . There was no significant difference in the use of prophylaxis in hospitals whose physicians received CME+QA interventions compared with hospitals whose physicians received CME interventions alone ( identical increases of 28 % ) . CONCLUSION A formal CME program significantly increased the frequency with which physicians prescribed prophylaxis for venous thromboembolism . We believe the key factor in our CME interventions that motivated clinicians to change their practice s was the provision of hospital-specific data demonstrating a compelling need for improvement . Despite the substantial investment by hospitals in QA , traditional QA intervention appeared to provide no additional benefit . Even after extensive CME/QA interventions , prophylaxis for venous thromboembolism remained underutilized , suggesting the need to develop new approaches to changing clinical practice The call for formal capacity assessment s of potential research participants with impairments due to illnesses such as Alzheimer 's disease is increasing . Because such an evaluation of every potential subject requires significant re sources , clinicians and research ers may want to know the utility and the limits of a familiar cognitive screening test , the  Mini Mental State Examination ( MMSE ) , in capacity evaluations . In this study of 37 patients with mild to moderate Alzheimer 's disease , a fairly wide range of  MMSE scores ( 21 to 25 , which includes an often used cutoff for " normal " ) did not discriminate capacity status well . Nevertheless , there may still be approaches that enhance the practical utility of the  MMSE  in capacity assessment OBJECTIVES Cases of antimicrobial resistance are increasing , partly due to inappropriate prescribing practice s by dentists . The purpose of this study was to investigate the prescribing practice s and knowledge of dentists with regards to antibiotics . Moreover , this study aim ed to determine whether the prescriptions comply with the recommended guidelines and whether clinical audit can alter the prescribing practice s of dentists leading to better use of antibiotics in the dental service . MATERIAL S AND METHODS A clinical audit ( before/after non-controlled trial ) was carried out in two dental clinics in the northeast of Engl and . Retrospective data were collected from 30 antibiotic prescriptions  , analysed and compared with the recommended guidelines . Data collected included age and gender of patients , type of prescribed antibiotics and their dosage , frequency and duration , clinical condition and reason for prescribing . The principles of appropriate prescribing based on guidance by the Faculty of General Dental Practice in the United Kingdom ( UK ) , FGDP , were discussed with the dental clinicians . Following this , prospect i ve data were collected and similarly managed . Pre and post audit data were then compared . Changes were tested for significance using McNemar 's test and P value<0.05 was considered statistically significant . RESULTS After intervention , data revealed that antibiotic prescribing practice s of dentists improved , as there was an increase in the percentage of prescriptions that were in accordance with the FGDP ( UK ) guidelines . CONCLUSION In view of the limited data collected , this study concludes that there are inappropriate antibiotic prescribing practice s amongst general dental practitioners and that clinical audit can address this situation , leading to a more rational use of antibiotics in dental practice BACKGROUND Procedural sedation guidelines were established for a tertiary care pediatric emergency department ( ED ) . We developed a pediatric procedural sedation course to disseminate these guidelines . OBJECTIVE Our objective was to evaluate the effectiveness of a sedation course in improving physicians ' knowledge of pediatric procedural sedation practice s and guidelines , relative to individual self-directed learning . METHODS We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a r and omized , controlled , educational intervention . All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment . Participants were r and omly assigned to one of 2 groups . The self-directed learning group ( n = 24 ) completed a multiple-choice examination without receiving any formal teaching . The study group ( n= 24 ) participated in a 4-hour formal multifaceted sedation course before writing the multiple-choice examination . RESULTS The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation . The formal teaching group 's median examination score ( 83.3 % ; range 75.8%-96.5 % ) was significantly higher ( p < 0.0001 ) than the median examination score of participants in the self-directed study group ( 73.3 % , range 43.5%-86.6 % ) . CONCLUSION The multifaceted sedation course was more effective in improving physician knowledge and underst and ing of sedation guidelines and practice s than unstructured , self-directed learning In March 2003 experts on interstitial cystitis ( IC ) from around the world met in Kyoto , Japan for a series of workshops intended to define areas of agreement and difference in the approach to this disease . This workshop explored the diagnostic criteria IC in the clinical and research setting s. The NIDDK criteria are used almost universally for research but there is tremendous disparity in the clinics and no consensus at all as to the best practice in diagnosing IC for clinical purpose s. Throughout the world many physicians use the NIDDK research criteria for clinical diagnosis ; in some countries this is st and ard . Undoubtedly , this m and ates under-diagnosis and denies treatment to many patients . Still , a majority feel that one diagnostic system is m and atory to promote clarity in communication . The group called for two initiatives to help advance this area of controversy : ( 1 ) a large-scale , prospect i ve study critically examining the role of  cystoscopy , bladder distention , and biopsy  in the diagnosis of IC ; ( 2 ) a concerted effort to develop a single evidence -based guideline or algorithm that would be flexible enough to meet the needs of clinicians , research ers , and patients BACKGROUND Antimicrobial prophylaxis in cardiac surgery has been demonstrated to lower the incidence of surgical site infection ( SSI ) . Inappropriate antimicrobial prophylaxis , such as inappropriate selection of the antimicrobial agent or inappropriate dosing regimen , can increase the prevalence of antibiotic resistant strains , prolong hospital stay , cause adverse reactions , and negatively affect an institution 's pharmacy budget for antibiotics . In developing countries such as Jordan , where the role of clinical pharmacists is still in its primary stages , the first step in establishing an organized clinical pharmacy service is the evaluation of current practice to determine the need for improvement . OBJECTIVE To assess the degree of adherence to international guidelines for antimicrobial prophylaxis practice in cardiac surgery performed at Queen Alia Heart Institute ( QAHI ) in Amman , Jordan , as part of an attempt to determine opportunities for clinical pharmacist intervention . METHODS For a total of 236 patients who were admitted for cardiac surgery to QAHI - the only official referral hospital for cardiac patients in Jordan - between November 19 , 2006 , and January 22 , 2007 , the antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were assessed against 3 international guidelines using a pre-tested , structured clinical data collection form that was completed by 2 of the authors who work at QAHI . The study design was prospect i ve . All patients who were scheduled for surgery were monitored daily during their inpatient stay until discharge and then were tracked in the outpatient clinic for 2 months following surgery . Data regarding antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were collected during the patient 's inpatient stay ; data collection was performed periodically thereafter as data became available until the end of the 2-month follow-up . The 3 guidelines agreed that ( a ) antimicrobial prophylaxis should be given to all patients undergoing cardiac surgeries ; ( b ) the first- or second-generation cephalosporins ( cefazolin or cefuroxime ) are the antibiotics of choice , and vancomycin use is reserved for cases of allergy to beta-lactams or if presumed or known methicillin-resistant Staphylococcus aureus ( MRSA ) colonization is present ; ( c ) the timing of the first dose should be within 60 minutes prior to the skin incision ; and ( d ) the duration of antimicrobial prophylaxis should not be longer than 48 hours . RESULTS Adherence to all antimicrobial prophylaxis guidelines was not achieved for any study patients . For the 6 evaluated criteria , ( 1 ) indication : in 100 % of patients the appropriate decision was made to use antimicrobial prophylaxis in concordance with guidelines ; ( 2 ) choice : only 1.7 % of patients received the antibiotic of choice ; ( 3 ) duration : 39.4 % of patents received antimicrobial prophylaxis for a total duration of 48 hours or less in concordance with guidelines , and for 58.9 % of patients , duration was longer than recommended ; ( 4 ) dose : 27.9 % of patients received an appropriate dose ; ( 5 ) dosing interval : only 13.0 % of patients received an appropriate dosing interval , and none of the doses of antimicrobial prophylaxis used at induction of anesthesia was repeated in operations that lasted longer than the half-life of the antibiotic used ; and ( 6 ) timing : 99.1 % of patients received antimicrobial prophylaxis dose within 60 minutes prior to skin incision as recommended by guidelines , but 97.0 % of patients received an unnecessary midnight dose of intravenous antibiotic the night before surgery . CONCLUSION Study findings indicate that adherence to international guidelines for antimicrobial prophylaxis is far from optimal in QAHI , leading to the inappropriate administration of many antibiotics . Developing local hospital guidelines , as well as giving the clinical pharmacist a central role in the administration , monitoring , and intervention of antimicrobial prophylaxis may improve the current practice OBJECTIVES The efficacy of cognitive behaviour therapies for psychosis ( CBTp ) has been sufficiently established for its inclusion in some national treatment guidelines . However , treatment efficacy does not guarantee effectiveness in routine practice , where clinician expertise and patient mix may be different . Thus , we evaluated the applicability , acceptability and effectiveness of CBTp when offered routinely in a public mental health service . DESIGN A prospect ively recruited representative sample ( N=94 ) of patients with psychotic disorders from a geographic catchment area in Melbourne , Australia , was r and omized to CBTp or treatment as usual . METHOD The CBTp intervention included psychoeducation , positive symptom , and co-morbid problem components . Therapists collaboratively negotiated goals with patients and utilized treatment components from a manual . Intention-to-treat analyses used data at baseline , 9 months and 18 months . RESULTS Working alliance and client satisfaction measures indicated excellent acceptability . Both groups improved to a similar degree on the Positive And Negative Syndrome Scale , with no advantage for the CBTp group . The most frequent CBTp components implemented were co-morbid disorders/personal issues and personalized psychoeducation ; working with persisting symptoms was the main focus in relatively few sessions . CONCLUSIONS The lack of advantage for the CBTp group may be due to : the infrequent focus on positive symptoms ( the most replicated outcome domain for CBTp ) ; the unselected nature of the patients ( rather than those with distressing symptoms or referred by clinicians ) ; or , to insufficient therapist expertise The aim of this editorial is to highlight several research priorities and key implication s for policy and practice that inform an agenda to improve family carer support . The development of systematic approaches to identify carers who are at risk of poor psychosocial outcomes  is a priority . Family caregiving should not be pathologised as an inherently negative experience ; however , it would be a breach of care if more than 40 % of carers who appear to meet the criteria for psychological distress1 are not offered suitable supports . Related to this is the urgent need for greater investment in bereavement research ; while bereavement support is integral to palliative care , it is typically under-re source d , under-investigated and not systematic ally applied . We know that routine intervention for all bereaved carers is not warranted . The challenge is to discern those carers who are ‘ at risk ’ prior to the death of the patient and to identify suitable evidence -based strategies to assist them . Research indicates that carer re sources , rather than patient diagnosis or illness severity , are the primary predictors of carer burden and other carer outcomes . This implies that although the specific content may need to vary to suit the context , the core elements of family carer interventions may be relevant across disease groups . It is also apparent that the perceived quality of social support is more important than the size of the social network in improving carer outcomes .2 Current indications are that palliative care providers should assist carers by targeting social support and re sources and provide education that focuses on coping strategies and preparation for the carer role . In many countries , family carers are well prepared for the beginning of life when , for example , prospect i ve parents are routinely offered parenting classes . It is also not uncommon to assist carers prepare for and support relatives having major heart surgery . However , preparation for supporting a relative/ friend at the end of their life is not routinely offered . Carers typically want to know what the role entails , how to manage symptoms , signs of imminent death and re sources and strategies to sustain their own well-being . Given the majority of patients want to be cared for in their home environment , initiatives that assist carers to achieve this are needed . The period of time most people receive palliative care services is typically quite short ; hence , the challenge is to design interventions that are as brief as possible , readily accessible and easily delivered . The significant number of carers who support patients in the hospital/hospice setting should also not be neglected ; their needs are often hidden . Other valuable insights regarding how we deliver interventions are surfacing . For example , the conception that face-to-face carer support is the gold st and ard is being challenged . Emerging evidence suggests that telephone and video phone support may be equally effective in some circumstances.1,3 Emphasis on the development of a strategic , coordinated and priority-driven family carer research agenda is also important.4 The role of formal research collaborations may be a vehicle to foster this . Much of the carer research seems to be first-world centric . More attention needs to be directed towards family caregiving in under-re source d countries and in other under-represented population s such as ethnic minority groups . Several important policy and clinical matters warrant consideration if palliative care is to foster improved carer support . One of the core questions for policymakers and clinicians is whether or not it is feasible for palliative care to be expected to meet the needs of the patients ’ entire family . It has been recommended that given re source constraints , the focus should be on the primary family carer ( as identified by the patient ) and where possible extended to other family members.5 Consideration might also be given to revising expectations about the goal of family support . The current World Health Organization definition of palliative care advocates that families ’ quality of life be improved ; perhaps a more realistic objective may be to aim to reduce the psychosocial burden of primary family carers . A related question is how to effectively legitimise family carer support . Most family carers do not want to discuss their needs and concerns in front of their relative ; they therefore need one-to-one time with healthcare and socialcare professionals . It is also clear that many healthcare workers find supporting carers challenging . Hence , where pertinent , consideration should be given to the potential merits of officially recognising family carers as ‘ care recipients ’ ; therefore , they are formally acknowledged as ‘ worthy ’ within the healthcare system . This may help justify much needed re sources and allow healthcare workers to allocate time and where pertinent offer interventions . In 488855 PMJ27710.1177/0269216313488855Palliative MedicineEditorial Context In the United States , what happens to incapacitated patients who lack surrogate decision makers  has not been quantified . Contribution This prospect i ve study of 3011 critically ill adults in 7 academically affiliated , geographically diverse intensive care units found that 5.5 % of the deaths occurred in patients who lacked a surrogate decision maker and an advance directive . Physicians and unit teams made life-support decisions without a formal hospital or court review for 30 of 37 such patients . Pertinent policies varied widely across hospitals and states . Caution Physicians self-reported information about decision making . Implication Physicians commonly make life-support decisions for patients who lack surrogate decision makers , without formal institutional or judicial review . The Editors The vast majority of deaths in intensive care units are preceded by a decision to limit life support ( 1 , 2 ) . Most critically ill patients can not participate in these decisions ( 1 , 3 ) . Consequently , the patients ' families generally function as surrogate decision makers ( 4 ) . However , some patients who lack decision-making capacity do not have a surrogate and have not completed an advance directive . Difficulties in making decisions for this patient population have been documented in skilled-nursing facilities ( 5 , 6 ) , general hospital wards ( 7 ) , and intensive care units of 1 major medical center ( 810 ) . These cases raise ethical and legal questions about who should make decisions for such patients and under what circumstances it is permissible to limit life-sustaining treatment . Although one third of physicians who care for critically ill patients have withdrawn life support in at least 1 patient who lacked decision-making capacity , a surrogate , and an advance directive , little is known about how frequently such decisions are made in intensive care units ( 11 ) . Professional organization guidelines differ on how decisions should be made for these patients . The American Medical Association ( AMA ) recommends ethics committee or judicial review , the American College of Physicians ( ACP ) recommends judicial review , and the American Geriatrics Society ( AGS ) advises against routine court involvement but recommends that decisions be made by clinicians caring for the patient ( 1214 ) . It is unknown what effect these recommendations have had on actual treatment decisions for incapacitated patients who lack a surrogate and an advance directive . Moreover , little is known about how decisions to limit life support are made for these patients . Therefore , we conducted a multicenter , prospect i ve study to determine the proportion of deaths in intensive care units that occur in patients who lack decision-making capacity , a surrogate , and an advance directive  and how decisions regarding life support are made for such patients . Methods Design , Patients , and Setting This multicenter , prospect i ve cohort study included all adults who were admitted to the medical or medical-surgical intensive care units of 7 hospitals in a 6-month period during 2004 to 2005 . The hospitals are located in California , Oregon , Washington , Pennsylvania , New York , and New Hampshire . Most of the study hospitals are located in metropolitan areas , and all have an academic affiliation . Several are county hospitals , and all are tertiary care centers . The number of beds in the intensive care units ranged from 8 to 16 . Other details regarding the study institutions have been deleted to protect the individual institutions and physicians from legal inquiry . The institutional review board at each hospital approved the study . We contacted the attending physician twice weekly to determine whether he or she had admitted any patients who lacked decision-making capacity , a surrogate , and an advance directive and , if so , whether there had been consideration of limiting life support in that patient . Patients were eligible if they lacked decision-making capacity and both a written advance directive and a surrogate decision maker . Because some physicians might not consider limiting life support without consent of the patient or a surrogate , we also included patients for whom a physician would have considered limiting life support if a family member had been available to act as a surrogate . Patients were considered to lack decision-making capacity if the attending physician determined that they could not participate in decisions about their medical care . We used the physicians ' assessment s of decision-making capacity rather than formal cognitive testing to capture how decisions were made in clinical practice , although physicians ' assessment s of decision-making capacity correlate highly with formal cognitive testing ( 15 ) . Written advance directives were defined as a document signed by the patient that delineated any aspect of their end-of-life treatment preferences . Patients were considered to lack a surrogate decision maker if they had no family , legally appointed guardian , or health care proxy available to participate in decisions about their medical care . Initial Evaluation and Follow-up If the attending physician indicated that withholding or withdrawing life-sustaining treatment had been considered or would have been considered if a surrogate had been available , he or she completed a question naire about the decision-making process that was vali date d in a separate pilot study for this project ( 10 ) . The question naire addressed patient and physician demographic characteristics , factors that influenced the decision of whether life-sustaining treatment should be limited , persons involved in the decision-making process , and whether the patient died in the intensive care unit . The question naire is available from the first author upon request . Physicians were told that the purpose of the study was to underst and processes of care for incapacitated patients without surrogates but were not informed of the specific research questions . At the end of the 6-month study period , we used administrative records from each institution to determine the number of admissions and deaths before discharge from the intensive care unit during the study period . We obtained written hospital policies that addressed how decisions about limiting life support should be made for incapacitated patients who lack a surrogate decision maker or an advance directive . We examined the published guidelines from the major U.S. medical societies ( AMA , ACP , and AGS ) and critical care organizations ( American Thoracic Society , American College of Chest Physicians , and Society for Critical Care Medicine ) to determine whether they had a policy for decision making in this population and , if so , what the policy was . In addition , a legal scholar research ed state laws to determine if relevant laws that addressed whether it is permissible to limit life support in these patients existed and , if so , the process by which these decisions should be made . We developed a categorization of groups that might be involved in the decision-making process , including , in increasing level of oversight , other members of the intensive care unit team ( nurses , fellows , and residents ) , another attending physician , hospital review ( an ethics committee , multidisciplinary committee , or patient ombudsman ) , and judicial review ( court ruling on the decision or a court-appointed guardian ) . At the end of the study , 3 investigators ( an ethicist , a lawyer , and a critical care physician ) together adjudicated whether each decision was made in accordance with hospital policy , professional society guidelines , and state statutes or court rulings . Legal Considerations Physicians may believe that they are in legal jeopardy if they limit life-sustaining treatment in a patient who can not provide informed consent and who lacks a surrogate decision maker and an advance directive . Therefore , we took several steps to protect the identities of physicians and patients . First , we removed from our data bases all information about the study hospitals , except the state in which they are located . Second , the study was anonymous for patients and physicians . Third , to minimize the chance that study records would allow a direct link between individual physicians and specific treatment decisions , we did not perform a chart review or collect identifying information . To protect individual physicians and institutions from legal scrutiny , we present the data on decision making in aggregate form only . Finally , we obtained a federal Certificate of Confidentiality from the National Institutes of Health that protects research data from subpoena in the event of a legal inquiry ( 16 ) . The Appendix provides more information about this Certificate . Role of the Funding Sources The funding sources had no role in the design , conduct , or analysis of this study or in the decision to su bmi t the manuscript for publication . Results A total of 3011 patients were admitted to intensive care units during the study period . Table 1 shows that the combined mortality rate for all intensive care units was 15.0 % ( 451 of 3011 patients ) . Overall , 5.5 % ( 25 of 451 patients ) of deaths in intensive care units occurred in incapacitated patients who lacked surrogate decision makers and advance directives . The percentage of deaths among incapacitated patients without surrogates ranged from 0 % to 27 % across the 7 study institutions ( Table 1 ) . Table 1 . Admissions and Deaths in the 7 Study Institutions * Decisions to Write a Do-Not-Resuscitate Order or to Withdraw Life Support There were 37 incapacitated patients who lacked decision-making capacity , a surrogate , and an advance directive for whom the attending physician considered or would have considered limiting life support if a surrogate had been available . Table 2 summarizes the demographic and clinical characteristics of these patients . They were predominantly male , white , and 40 years of age or older . Table 2 . Characteristics of the 37 Incapacitated Patients without Surrogates In these The Scottish Intercollegiate Guidelines Network ( SIGN ) develops evidence based clinical guidelines for the NHS in Scotl and . The key elements of the methodology are ( a ) that guidelines are developed by multidisciplinary groups ; ( b ) they are based on a systematic review of the scientific evidence ; and ( c ) recommendations are explicitly linked to the supporting evidence and grade d according to the strength of that evidence . Until recently , the system for grading guideline recommendations was based on the work of the US Agency for Healthcare Research and Quality ( formerly the Agency for Health Care Policy and Research ) . 1 2 However , experience over more than five years of guideline development led to a growing awareness of this system 's weaknesses . Firstly , the grading system was design ed largely for application to questions of effectiveness , where r and omised controlled trials are accepted as the most robust study design with the least risk of bias in the results . However , in many areas of medical practice r and omised trials may not be practical or ethical to undertake ; and for many questions other types of study design may provide the best evidence . Secondly , guideline development groups often fail to take adequate account of the method ological quality of individual studies and the overall picture presented by a body of evidence rather than individual studies or they fail to apply sufficient judgment to the overall strength of the evidence base and its applicability to the target population of the guideline . Thirdly , guideline users are often not clear about the implication s of the grading system . They misinterpret the grade of recommendation as relating to its importance , rather than to the strength of the supporting evidence , and may therefore fail to give due weight to low grade recommendations . # # # # Summary points A revised system of determining levels of evidence and grade s Double-blind , r and omised controlled studies represent the gold-st and ard approach to determine the safety and efficacy of therapeutic interventions . In chronic conditions such as rheumatoid arthritis ( RA ) , long-term data are vital to confirm maintenance of effect and identify potential safety signals . The recent introduction of numerous biological therapies for RA has been followed by various long-term extension ( LTE ) studies . Although useful , the design and method of analysis in such studies vary significantly , partly due to their complexity . This viewpoint highlights general considerations needed when undertaking a LTE study and illustrates the lack of consistency in studies of RA to date . It addresses issues of selection bias , patient discontinuation and missing data . Although used for safety reporting , the lack of adequate powering makes LTE studies of limited benefit . Ethical considerations and challenges are highlighted , including potential conflicts of interest . Finally , the authors suggest the need for consensus to ensure more reliable interpretation and application of data for clinical practice . Following the development of guidelines on reporting of clinical trials in RA and more recently , registry data , a similar approach for LTE studies would be a useful endeavour
Conclusions : Antibiotic prophylaxis did confer a reduction in cases of symptomatic and asymptomatic bacteriuria but the NNT were high .
Introduction : The role of antibiotic prophylaxis for routine flexible cystoscopy ( FC ) is not clear due to the varying practice s of individual clinicians .
There are no formal guidelines , and this may be due to a lack of formal summary of the data .