Association of hydroxyurea adherence with transcranial Doppler screenings in children with sickle cell disease

BACKGROUND

National sickle cell disease (SCD) guidelines recommend oral hydroxyurea (HU) starting at 9 months of age, and annual transcranial Doppler (TCD) screenings to identify stroke risk in children aged 2-16 years. We examined prevalence and proportion of TCD screenings in North Carolina Medicaid enrollees to identify associations with sociodemographic factors and HU adherence over 3 years.

STUDY DESIGN

We conducted a longitudinal study with children ages 2-16 years with SCD enrolled in NC Medicaid from years 2016-2019. Prevalence of TCD screening claims was calculated for 3 years, and proportion was calculated for 12, 24, and 36 months of Medicaid enrollment. Enrollee HU adherence was categorized using HU proportion of days covered. Multivariable Poisson regression assessed for TCD screening rates by HU adherence, controlling for age, sex, and rurality.

RESULTS

The prevalence of annual TCD screening was between 39.5% and 40.1%. Of those with 12-month enrollment, 77.8% had no TCD claims, compared to 22.2% who had one or higher TCD claims. Inversely, in children with 36 months of enrollment, 36.7% had no TCD claims compared to 63.3% who had one or higher TCD claims. The proportion of children with two or higher TCD claims increased with longer enrollment (10.5% at 12 months, 33.7% at 24 months, and 52.6% at 36 months). Children with good HU adherence were 2.48 (p < .0001) times more likely to have TCD claims than children with poor HU adherence.

CONCLUSION

While overall TCD screening prevalence was low, children with better HU adherence and longer Medicaid enrollment had more TCD screenings. Multilevel interventions are needed to engage healthcare providers and families to improve both evidence-based care and annual TCD screenings in children with SCD.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies

AIM

To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments.

METHODS

A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made.

RESULTS

Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation.

CONCLUSION

Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Tranexamic Acid Use in Obstetric Hemorrhage: Knowledge and Attitude Among Jordanian Obstetricians and Gynecologists

AIM

Tranexamic acid (TXA) use in obstetric hemorrhage has been shown to decrease both maternal mortality and morbidity. This study aimed to explore the knowledge and attitudes of Jordanian obstetricians and gynecologists regarding the use of TXA in obstetric bleeding cases, as well as to identify factors that affect decision-making processes and emphasize the significance of TXA in enhancing maternal health outcomes.

METHODOLOGY

This study used a cross-sectional design and a structured questionnaire to gather data from a convenience sample of 1000 Jordanian obstetricians.

RESULTS

Most participants used TXA to address obstetric hemorrhage, with medical training being the primary source of knowledge about TXA for (113/166) 68.1% of respondents. Awareness of TXA's potential benefits was high but some misconceptions existed. Approximately (96/166) 57.8% of the participants were aware of the recommended dosage regimen, and (61/166) 36.7% emphasized the importance of timing of administration. Knowledge of potential side effects was notable, with (55/166) 33.1% aware of life-threatening side effects, such as pulmonary embolism and deep vein thrombosis. Concerns regarding barriers to implementation included the absence of strict guidelines (54.8%) and drug availability ( 91/166; 54.8%). However, (64/166) 38.6% expressed confidence in the effective use of TXA for obstetric hemorrhage treatment. The majority of respondents (154/166; 92.8%) considered additional education and training on TXA use to be important in managing obstetric hemorrhage.

CONCLUSION

Jordanian obstetricians have used TXA in cases of obstetric hemorrhage despite their experience and knowledge based only on limited resources; the need for national guidelines on when and how to use TXA in obstetric practice is of great importance and got vast support from the Jordanian obstetricians.

Barriers and facilitators to national guideline implementation for palliative cancer care in a Danish cross-sectoral healthcare setting: A qualitative study of healthcare professionals' experiences

OBJECTIVE

Patients with incurable cancer should receive general palliative care according to their needs, as provided through collaboration between hospital departments, municipalities, and general practices and as outlined in national guidelines. However, the implementation of general palliative care in Denmark has been inadequate. This study aimed to investigate the healthcare professionals' (HCPs') perceptions on barriers to and facilitators of the implementation of the Danish National Guideline (NG) for general palliative care.

METHODS

This descriptive, qualitative study was guided by the Consolidated Framework for Implementation Research (CFIR). Qualitative focus group and individual interviews were conducted with 23 HCPs. The interview guide, coding, analysis, and reporting of findings were developed within the CFIR framework.

RESULTS

The main barriers to implementing NG were as follows: lack of knowledge about the NG, lack of an implementation plan, and insufficient communication and collaboration across sectors. Important facilitators were as follows: HCP motivation to meet palliative care needs, HCPs with special functions taking responsibility for incorporating NG into local guidelines, and the role of district nurses specialised in palliative care as opinion leaders providing security and continuity for the HCPs working in palliative care.

CONCLUSIONS

To address the needs of patients with incurable cancer, greater efforts are required on implementing general palliative care. Although HCPs in our setting were motivated to improve NG implementation, financial resources and strategies are necessary to ensure sufficient knowledge uptake and accommodate identified barriers in order to translate the NG into practice.

Knowledge and practice of preparticipation physical evaluation of Saudi primary care physicians in the Eastern Province of Saudi Arabia

BACKGROUND

The preparticipation physical evaluation (PPE) monograph is a vital resource for medical providers aimed at ensuring the safety and well-being of athletes during sports participation by screening for injuries and disease risk factors. However, the concept of PPE is relatively new in Saudi Arabia, where primary care physicians (PCPs) often lack the proper training for it. This study's aim was to assess PCPs' knowledge and practice of PPE and identify associated factors.

MATERIALS AND METHODS

A self-administrated web-based questionnaire was distributed to PCPs in the Eastern Province of Saudi Arabia. The questionnaire covered the various aspects of PPE knowledge (including general principles, components, contraindications of sports participation, concerning history and physical findings, electrocardiography interpretations, and ethical considerations) as well as PPE practice. Initial treatment of data included descriptive statistics.; Chi-square tes or Fisher's exact test as, as appropriate, were used to determine association of knowledge and practices with various independent variables.

RESULTS

Of the 240 contacted PCPs, 192 responded yielding a response rate of 80%; 50.5% had no prior PPE training. About 43% of the PCPs had not encountered PPE during their examination, but the remainder performed monthly PPE. Notably, 82.8% demonstrated a poor level of knowledge regarding PPE and only 43% had a satisfactory level of practice.

CONCLUSION

This study revealed that a significant proportion of PCPs displayed poor knowledge of PPE and <½ of our sample showed satisfactory practice levels. Recommendations to establish the local guidelines regarding PPE for PCPs to follow should be emphasized and PPE training integrated into both undergraduate and postgraduate family medicine curricula. These measures are crucial for the enhancement of the safety of athletes in Saudi Arabia.

Re-irradiation in Paediatric Tumours of the Central Nervous System: National Guidelines from the Swedish Workgroup of Paediatric Radiotherapy

There is a lack of clinical protocols for re-irradiation in paediatric central nervous system (CNS) tumours. To fill this void, the Swedish Workgroup of Paediatric Radiotherapy (SBRTG) compiled national guidelines on re-irradiation in paediatric CNS tumours (diffuse intrinsic pontine glioma, ependymoma, germinoma and medulloblastoma). These have been in clinical practice since 2019 in all paediatric radiotherapy centres in Sweden. Since the implementation, the guidelines have been complemented with a yearly review on clinical outcome and toxicities in all paediatric patients treated according to the guidelines. This article presents the Swedish national guidelines on re-irradiation in paediatric CNS tumours.

Evaluating national guidelines for monitoring early growth using routinely collected data in Bergen, Norway

AIMS

The overarching aim of this study was to evaluate the Norwegian guidelines for growth monitoring using routinely collected data from healthy children up to five years of age. We analysed criteria for both status (size for age) and change (centile crossing) in growth.

METHODS

Longitudinal data were obtained from the electronic health record (EHR) at the well-baby clinic for 2130 children included in the Bergen growth study 1 (BGS1). Measurements of length, weight, weight-for-length, body mass index (BMI) and head circumference were converted to z-scores and compared with the World Health Organization (WHO) growth standards and the national growth reference.

RESULTS

Using the WHO growth standard, the proportion of children above +2SD was generally higher than the expected 2.3% for all traits at birth and for length at all ages. Crossing percentile channels was common during the first two years of life, particularly for length/height. By the age of five years, 37.9% of the children had been identified for follow-up regarding length/height, 33% for head circumference and 13.6% for high weight-for-length/BMI.

CONCLUSIONS

The proportion of children beyond the normal limits of the charts is higher than expected, and a surprisingly large number of children were identified for rules concerning length or growth in head circumference. This suggests the need for a revision of the current guidelines for growth monitoring in Norway.

Evolution of National Guidelines on Medicines Used to Treat COVID-19 in Pregnancy in 2020-2022: A Scoping Review

The lack of inclusion of pregnant women in clinical trials evaluating the effectiveness of medicines to treat COVID-19 has made it difficult to establish evidence-based treatment guidelines for pregnant women. Our aim was to provide a review of the evolution and updates of the national guidelines on medicines used in pregnant women with COVID-19 published by the obstetrician and gynecologists' societies in thirteen countries in 2020-2022. Based on the results of the RECOVERY (Randomized Evaluation of COVID-19 Therapy) trial, the national societies successively recommended against prescribing hydroxychloroquine, lopinavir-ritonavir and azithromycin. Guidelines for remdesivir differed completely between countries, from compassionate or conditional use to recommendation against. Nirmatrelvir-ritonavir was authorized in Australia and the UK only in research settings and was no longer recommended in the UK at the end of 2022. After initial reluctance to use corticosteroids, the results of the RECOVERY trial have enabled the recommendation of dexamethasone in case of severe COVID-19 since mid-2020. Some societies recommended prescribing tocilizumab to pregnant patients with hypoxia and systemic inflammation from June 2021. Anti-SARS-CoV-2 monoclonal antibodies were authorized at the end of 2021 with conditional use in some countries, and then no longer recommended in Belgium and the USA at the end of 2022. The gradual convergence of the recommendations, although delayed compared to the general population, highlights the importance of the inclusion of pregnant women in clinical trials and of international collaboration to improve the pharmacological treatment of pregnant women with COVID-19.

Overweight children in rural Norway - public health nurses' possibilities and limitations within national guidelines

INTRODUCTION

Globally, overweight and obesity are more prevalent in rural areas than in urban areas. The purpose of this study was to determine to what extent public health nurses in rural areas in Norway feel equipped to tackle the overweight and obesity epidemic within two sets of national guidelines: The National Guidelines for the Standardized Measurement of Height and Weight and The National Guidelines for the Prevention, Identification, and Treatment of Overweight and Obesity in Children and Adolescents. These guidelines are inspired by New Public Management (NPM) logic, which emphasises more market orientation within the public sector to obtain a more cost-effective supply of public goods. The focus is on the weighing of schoolchildren, available resources, inter-agency cooperation and the rural context.

METHODS

The data were collected using a structured questionnaire among 40 public health nurses working with children in rural areas, as well as qualitative interviews with 25 informants involved in the prevention and treatment of overweight and obesity among rural children.

RESULTS

The study shows that rural public health nurses worry about the lack of resources for follow-up with children with a body mass index greater than what is characterised as 'normal'. The public health nurses suggested better cooperation between different stakeholders to work around the lack of resources and at the same time be able to see the whole picture, considering that overweight and obesity are complex problems connected to different challenges. They believed that it is an advantage to see the individuals in their local surroundings, to know their family history, their leisure activities and so on. This might be easier in rural areas than in urban areas, as these areas are often more transparent.

CONCLUSION

There was consensus among the public health nurses involved in this study that national guidelines for treating overweight and obesity in children with the principles of NPM, and simplifying and standardising services, adds challenges instead of solutions. Such practices also hinder the use of experience-based knowledge about both the individual and the local context. There is a need for more flexible guidelines that can easily be adapted to the local (rural) context.

Prevention and management of childhood progressive myopia: National consensus guidelines

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

Leflunomide Induced Atypical DRESS: A Case Report and Literature Review

Drug rash with eosinophilia and systemic symptoms syndrome (DRESS syndrome) is a potentially life-threatening, drug-induced, multi-organ system reaction, the most frequently involved organ is liver, followed by the kidneys and lungs.¹ Early detection and diagnosis followed by withdrawal of the offending agent is vital to minimise the associated morbidity and mortality. A detailed drug history is vital to identify the causative drugs. Although Spanish guidelines were developed by a panel of allergy specialists from the Drug Allergy Committee of the Spanish Society of Allergy and Clinical Immunology (SEAIC) and are available in literature from 2020, many clinicians are still unaware about the management of this syndrome. Framing national guidelines for the early diagnosis and Pharmaco-therapeutic management of DRESS will help the healthcare professionals to save the patients from unintended vulnerability. Leflunomide, a drug widely used in rheumatology and orthopaedics must be used with caution since it has the potential to cause DRESS syndrome. We report a case of a lady aged 32 years, presented to our hospital with a history of leflunomide intake and symptoms of DRESS.

Tilting the Scale: Current Provider Perspectives and Practices on Breastfeeding with HIV in the United States

The risk of vertical transmission from breastfeeding with HIV (BFHIV) has been found to be very low in optimal scenarios with sustained maternal viral suppression during pregnancy and postpartum. Medical providers must account for the risk of this serious adverse event alongside parental autonomy, breastfeeding benefits, and patient values. To assess provider practices, comfort, and challenges with BFHIV, an online mixed-method survey was sent to breastfeeding and HIV provider listservs from June to July 2021. The target population was US medical professionals from diverse practice settings with experience in clinical issues associated with BFHIV, including physicians, advanced practice providers, nurses, and lactation consultants. Data analysis utilized nonparametric hypothesis testing, ordinal regression, and reflexive thematic analysis. Most providers reported counseling pregnant people with HIV on infant feeding choices, but fewer specifically endorsed counseling about breastfeeding. Of 84 unique institutions identified by 100 included respondents, 10% had an institutional protocol supporting BFHIV. Institutional protocols were associated with higher degrees of provider comfort with BFHIV in optimal scenario clinical vignettes. Providers perceived that White patients faced fewer BFHIV barriers than patients with other racial identities. Discomfort balancing the goals to protect infants from infection risk and support the parent's role in infant feeding decisions was a key theme in free text responses; this manifested in a spectrum of management styles ranging from patient's informed choice to paternalism. This study highlights the tension providers navigate regarding BFHIV discussions, calling for patient care guidelines and protocols grounded in risk reduction and respect of patient autonomy.

Antibiotic prescriptions for child sinusitis varied between specialties after Finnish guidelines were updated in 2018

AIM

We evaluated antibiotic prescriptions issued for Finnish children with acute sinusitis by a nationwide private outpatient clinic network from 2014-2020. Data were compared before and after updated guidelines in 2018.

METHODS

The study comprised data on 45 296 children aged 2-17 years with acute sinusitis, namely diagnoses, ages, dates, the doctor's specialty and any antibiotics. We measured compliance with the updated 2018 Finnish guidelines, which recommended amoxicillin or amoxicillin-clavulanic acid for children under 12 years old, with doxycycline as an alternative for 12 years plus.

RESULTS

There were 6621-7585 visits per year for acute sinusitis in 2014-2019 and 2954 in 2020. Antibiotics were prescribed for 37.9%-41.6% of patients during the study years. Amoxicillin, including penicillin, accounted for 35.9% of prescriptions, followed by amoxicillin-clavulanic acid (26.9%). Macrolides accounted for 20.6% and, encouragingly, decreased by 38% from 2014-2019. Doxycycline accounted for 5.3%. Paediatricians, general practitioners (GPs) and ear, nose and throat specialists followed the guidelines in 75.1%, 73.8% and 66.7% of cases, respectively. GPs prescribed antibiotics more often than other physicians.

CONCLUSION

Antibiotics were prescribed for about 40% of acute sinusitis visits by Finnish children from 2014-2019. Specialities differed with regard to prescribing rates and whether they followed the guidelines.

Clozapine haematological monitoring for neutropenia: a global perspective

AIMS

Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates.

METHOD

We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons.

RESULTS

One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita.

CONCLUSIONS

Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools

OBJECTIVE

To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma.

METHODS

Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care.

RESULTS

We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV₁% predicted and FEV₁/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively).

CONCLUSIONS

Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03032744.

National suicide management guidelines recommending family-based prevention, intervention and postvention and their association with suicide mortality rates: systematic review

BACKGROUND

Suicidal behaviour remains a major public health concern and countries have responded by authoring guidelines to help mitigate death by suicide. Guidelines can include family-based recommendations, but evidence for the level and category of family-based involvement that is needed to effectively prevent suicide is unclear.

AIMS

To explore the association between family-based recommendations in guidelines and countries' crude suicide rates. PROSPERO registration: CRD42019130195.

METHOD

MEDLINE, Embase, PsycInfo, Web of Science and WHO MiNDbank databases and grey literature were searched within the past 20 years (1 January 2000 to 22 June 2020) for national guidelines giving family-based recommendations in any of three categories (prevention, intervention and postvention).

RESULTS

We included 63 guidelines from 46 countries. All identified guidelines included at least one family-based recommendation. There were no statistically significant differences seen between mean World Health Organization crude suicide rates for countries that included only one, two or all three categories of family-based recommendations. However, a lower spread of crude suicide rates was seen when guideline recommendations included all three categories (mean crude suicide rates for one category: 11.09 (s.d. = 5.71); for two categories: 13.42 (s.d. = 7.76); for three categories: 10.68 (s.d. = 5.20); P = 0.478).

CONCLUSIONS

Countries should work towards a comprehensive national suicide guideline that includes all categories of family-based recommendations. Countries with previously established guidelines should work towards the inclusion of evidence-based recommendations that have clear implementation plans to potentially help lower suicide rates.

National and State Level Opioid-Restricting Legislation in Total Joint Arthroplasty: A Systematic Review

BACKGROUND

The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA.

METHODS

Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA).

RESULTS

We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies.

CONCLUSION

Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

The Implementation of Mindfulness-Based Programs in the Swedish Healthcare System-A Qualitative Study

Background:

As the provision of Mindfulness-Based Programs (MBPs) in health care settings progresses, more research is needed to develop guidelines and structures for implementation in various contexts. This study is part of a larger project were MBP provision in Sweden is explored.

Objective:

The objective is to provide knowledge for the next steps of MBP implementation both in Sweden and internationally. The specific aim of the study is to explore how MBP teachers and other relevant stakeholders experience the implementation of MBP.

Methods:

Qualitative in-depth interviews were conducted with 15 MBP providers and 2 other stakeholders from a range of health care settings in Sweden.

Results:

The results, presented in 3 themes, provide insights into the factors that are crucial for facilitating or hindering MBP implementation; (1) MBP teachers and their training, including the importance of champion individuals and the benefit and shortcomings of various forms of MBP; (2) Patients and patient referrals, including patient characteristics and referral pathways; (3) Organizational prerequisites to successful implementation, highlighting the importance of financial factors and managers’ and colleagues’ knowledge and acceptance of MBP; and (4) the need for structural changes, including future recommendations on quality assessment and guidelines.

Conclusion:

This study highlights the need for national guidelines for MBP provision and teacher training pathways, as well as improved availability of teacher training. Also, the benefit of a stepped-care model of MBP provision is indicated by the findings. Finally, increasing awareness of MBPs among referrers, managers, and the public may enable successful implementation.

Antibiotic Prescribing Habits and Antimicrobial Resistance Awareness of Dental Practitioners in Primorsko-Goranska County, Croatia

Purpose: The goal of this study was to investigate the differences in dentists' knowledge, attitudes, and practice regarding antibiotic use and resistance among two areas of Primorsko-Goranska County (P-GC), Croatia. Materials and Methods: A cross-sectional study based on a structured questionnaire that was given to 230 dental practitioners in outpatient settings of P-GC in 2018. Results: The overall response rate was 68.3% (157/230) and 72.2% (83/115) in the city of Rijeka and 64.3% (74/115) in the rest of P-GC. Dentists from two areas of P-GC held similar knowledge about prescribing antibiotics and attitudes regarding antibiotic use (p > 0.05). Most of the dental practitioners chose penicillins (65.0% amoxicillin with clavulanic acid and 33.1% amoxicillin) as the first-choice antibiotic in patients with no medical allergies. The trend of prescribing amoxicillin decreases with the age of the dentists (p = 0.046). Clindamycin (86.6%) was the first choice for patients allergic to penicillin. Postgraduate education changed the attitude toward taking more time to consider whether or not an antibiotic is needed. Croatian dentists had a high awareness of antimicrobial resistance (99.4%). The most common situations for which dentists would prescribe antibiotics were periapical abscess (84.7%), periodontal abscess (72.6%), and implant placement (59.9%). Patient request or expectation (43.4%) and treatment uncertainty (41.5%) were found to be the main factors for prescribing antibiotics with more frequency. Conclusions: Although there is a high level of antimicrobial resistance awareness among dental practitioners, there is still too much overuse of antibiotics and personal responsibility for prudent antibiotic use should be increased. The results of this study indicate that antibiotics are frequently prescribed for indications where surgical treatment should be the first option and the broad spectrum antibiotic is the preferred treatment option.

Dementia Care Education Targeting Job Strain and Organizational Climate Among Dementia Care Specialists in Swedish Home Care Services

Introduction

An increasing number of older persons live at home with various limitations, such as dementia, requiring well-educated and trained home care staff to meet their complex care needs. Dementia care specialists working in home care service have reported high levels of job strain in comparison with home care staff in general.

Aim

This pilot study aims to evaluate the effects of a dementia care education model targeting self-reported job strain and organizational climate, among dementia care specialists in home care service.

Methods

A quasi-experimental, one-group pretest–posttest design was applied, with 12 months’ follow-up. Participants were dementia care specialists who worked in home care service (n=34 baseline; n=30 follow-up). The data were collected using the Strain in Dementia Care Scale and Creative Climate Questionnaires, administered pre- and post-intervention. The intervention applied an educational model based on previous research in dementia care and a person-centered approach.

Results

The educational model was implemented in the context of home care services. Of 34 participants at baseline, only 21 responded to the questionnaires, due to a drop off of 13 participants and recruitment of 9 new participants (follow-up=30). A significantly reduced perceived job strain among the participants was detected, indicating perceiving less difficulty in “Balancing competing needs” when caring for the older persons. No significant difference was found in the self-reported creative organizational climate between the two occasions.

Conclusion

The educational model could be integrated into dementia home care and it seemed to reduce job strain among dementia care specialists. Future studies are needed to evaluate the effects of the intervention using a stronger study design and a larger sample.

Assessment of Use of National Guidelines for Malaria Case Management among Pediatric Resident Doctors Attending an Update Course in Benin City, Nigeria

Introduction:

The National Malaria Guideline is a veritable tool for appropriate case management of malaria. Whether the pediatric residents who are the primary caregivers of children know and make use of this guideline in their routine practice is not yet assessed.

Aim:

The aim of the study is to assess the awareness of the Nigerian pediatric residents of the national guidelines for malaria case management (including antimalarial prescription for uncomplicated and severe malaria).

Settings and Design:

The descriptive study carried out during the 2017 National Postgraduate Medical College of Nigeria, Faculty of Paediatrics Update Course in Benin City.

Subjects and Methods:

Data were obtained using a self-administered questionnaire which was given to all pediatric residents who participated at the update course and who had given written informed consent.

Statistical Analysis Used:

The statistical analysis was done using the Statistical Package for the Social Sciences version 16.0 (Inc., Chicago, Illinois, USA).

Results:

Of the 108 participants whose questionnaires were analyzed, 75.0% were Part 1 candidates and 25.0% Part 2 candidates; mean age 34.0 ± 4.5 years (range 26–51 years) and 42 (39.0%) males while 66 (61.0%) were female. Ninety-four (87.0%) were aware of the current national guidelines for management of malaria and 45 (41.7%) had read the guidelines. Correctness of prescription was obtained from 39 (36.0%) respondents in uncomplicated malaria cases and 44 (40.7%) in severe malaria cases. This finding did not significantly associate with the years of practice, level of practice, practicing institutions, awareness, and reading of the national guideline.

Conclusions:

Most pediatric residents have not read nor use the national guidelines for management of malaria which reflected in poor prescription pattern of antimalarial drugs in routine practice.

A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis

Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed.Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden.Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines.Conclusion: To increase adherence, it is important to consider doctors' preconceptions when creating new guidelines.

The National Palliative Care Registry: A Decade of Supporting Growth and Sustainability of Palliative Care Programs

Background: Palliative care program service delivery is variable, and programs often lack data to support and guide program development and growth. Objective: To review the development and key features of the National Palliative Care Registry™ ("the Registry") and describe recent findings from its surveys on hospital palliative care. Description: Established in 2008, the Registry data elements align with National Consensus Project (NCP) guidelines related to palliative care program structures and operations. The Registry provides longitudinal and comparative data that palliative care programs can use to support programmatic growth. Results: As of 2018, >1000 hospitals and 120 community sites have submitted data on their palliative care programs to the Registry. Over the past decade, the percentage of hospital admissions seen by palliative care teams (penetration) has increased from 2.5% to 5.3%. Higher penetration is correlated with teaching hospital status, having a palliative care trigger, and hospital size (p < 0.05). Although overall staffing has expanded, only 42% of Registry programs include the recommended four key disciplines: physician, advanced practice or other registered nurse, social worker, and chaplain. Compliance with NCP guidelines on key structures and processes vary across adult and pediatric programs. Conclusions: The Registry allows palliative care programs to optimize core structures and processes and understand their performance relative to their peers.

Swedish guidelines for registry-based randomized clinical trials

During the last decade Sweden has invested in a national infrastructure for collection of structured clinical data in the form of healthcare registries (in Sweden known as Kvalitetsregister). These data can be combined with other public data using the national personal identifiers that are issued to Swedish citizens. The healthcare registries have an almost complete coverage of Swedish healthcare, and a large network of clinicians is involved in the quality assurance and continuous improvement of healthcare using these registries. Uppsala Clinical Research Center (UCR) has been a technology provider of large-scale national registries and has a strong background in clinical trial management. This effort combines the areas of healthcare registries and clinical trials into a novel way of performing clinical trials to be able to: 1) run clinical trials as an integrated part of normal clinic workflow; and 2) leverage the nationwide network of outcome reporting. This strategy was shown to be successful in the TASTE (Thrombus Aspiration in Myocardial Infarction) study. When TASTE had been published, the New England Journal of Medicine wrote a perspective on the study calling it 'The randomized registry trial-the next disruptive technology in clinical research?' Since then several studies have been conducted in this way with great success. UCR has been appointed, by Clinical Studies Sweden and the Swedish Research Council, to develop the Swedish national guidelines for registry-based randomized clinical trials in order to ensure the possibility for more organizations to run this kind of study. This paper describes key concepts of register-based randomized clinical trials and the development of Swedish national guidelines.

[Acute uncomplicated cysititis: do we follow the guidelines?]

INTRODUCTION

Lower urinary tract infection are a common urologic disease, but a therapy is not always optimal.

AIM

to evaluate the compliance of prescriptions made by urologists in treatment of patients with lower urinary tract infection, in particular with acute uncomplicated cystitis.

MATERIALS AND METHODS

A specially designed questionnaire was filled out by 161 urologists from Novosibirsk, Barnaul and Krasnoyarsk, as well as participants of VII Congress of urologists of Siberia.

RESULTS

The survey showed that 34.8%, 27.9%, 22.4% and 14.9% of urologists had 6-10, 11-20, 1-5 and more than 20 patients with acute uncomplicated cystitis a month, respectively. According to results, 91.9% of urologists are familiar to National guidelines on treatment of lower urinary tract infections and 91.2% of doctors consider them to be reasonable. Among those surveyed, 29.2% of urologists believe that National Guidelines differ from European Guidelines; 95.7% of participants adhere to recommendations, but only 47.4% respect it almost always, 16.9% do it in half of cases and the remaining 35.7% comply with them in less than 40% cases. Moreover, 86.4% of urologists started a treatment of acute cystitis with antimicrobial therapy and preferred fosfomycin in 41.0%, nitrofurans in 20.9%, fluoroquinolones in 21.6% and cephalosporins in 16.5% cases, respectively. Almost all respondents (93.8%) are convinced that antibiotic therapy should be accompanied by phytotherapy, and 71.5% of urologists administer Canephron.

CONCLUSION

In the urologic community there are controversies in the treatment of patients with acute uncomplicated cystitis. The choice of therapy is not always optimal.

Axillary Surgery in Breast Cancer Patients Treated with Breast-Conserving Surgery at German Breast Cancer Centers Within the Last 14 Years - Comparison of a University Center and a Community Hospital

Background Guideline recommendations for axillary surgical approach in breast cancer (BC) treatment changed over the last decade.

Methods Data from all invasive BC patients (n = 5344) treated with breast conserving surgery (BCS) at the breast cancer centers of the University Hospital Ulm (U-BCC) and the community hospital Dachau (D-BCC) were included into a retrospective analysis for assessing information on axillary surgery between 2003 and 2016 based on the documented cancer registry data.

Results The average annual rate of sentinel node biopsy (SNB) was 85.5% and 87.2% in Ulm and Dachau, respectively. SNB was performed more precisely at the U-BCC with a median of 2.4 resected lymph nodes (LN) compared to a median of 3.2 resected LN in Dachau. Median number of resected LN for axillary lymph node dissection (ALNE) showed a statistically significant reduction over time in Ulm (r _s  = − 0.82; p < 0.001) and Dachau (r _s  = − 0.76; p = 0.002). The rate of secondary ALNE (after SNB; 2° ALNE) decreased significantly in U-BCC (r _s  = − 0.76; p = 0.002) while it remained stable in D-BCC. The influential publication of the Z0011 study in 2010 resulted in a significant reduction of secondary ALNE (24.1% preZ0011 and 14.4% postZ0011; p < 0.001) in Ulm.

Conclusion Changes in axillary surgery over time can be seen in the annual statistics of the reviewed BCCs. With BCS, mostly SNB was performed and numbers of removed LN in ALNE have decreased. In the U-BCC, the rate of 2° ALNE dropped after the publication of the Z0011 data. The fact that no such decrease for 2° ALNE was found in D-BCC suggests that university hospitals implement new data and research results into clinical routine earlier than peripheral community hospitals.

Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy

Small for gestational age is usually defined as an infant with a birthweight <10th centile for a population or customized standard. Fetal growth restriction refers to a fetus that has failed to reach its biological growth potential because of placental dysfunction. Small-for-gestational-age babies make up 28-45% of nonanomalous stillbirths, and have a higher chance of neurodevelopmental delay, childhood and adult obesity, and metabolic disease. The majority of small-for-gestational-age babies are not recognized before birth. Improved identification, accompanied by surveillance and timely delivery, is associated with reduction in small-for-gestational-age stillbirths. Internationally and regionally, detection of small for gestational age and management of fetal growth problems vary considerably. The aim of this review is to: summarize areas of consensus and controversy between recently published national guidelines on small for gestational age or fetal growth restriction; highlight any recent evidence that should be incorporated into existing guidelines; and identify future research priorities in this field. A search of MEDLINE, Google, and the International Guideline Library identified 6 national guidelines on management of pregnancies complicated by fetal growth restriction/small for gestational age published from 2010 onwards. There is general consensus between guidelines (at least 4 of 6 guidelines in agreement) in early pregnancy risk selection, and use of low-dose aspirin for women with major risk factors for placental insufficiency. All highlight the importance of smoking cessation to prevent small for gestational age. While there is consensus in recommending fundal height measurement in the third trimester, 3 specify the use of a customized growth chart, while 2 recommend McDonald rule. Routine third-trimester scanning is not recommended for small-for-gestational-age screening, while women with major risk factors should have serial scanning in the third trimester. Umbilical artery Doppler studies in suspected small-for-gestational-age pregnancies are universally advised, however there is inconsistency in the recommended frequency for growth scans after diagnosis of small for gestational age/fetal growth restriction (2-4 weekly). In late-onset fetal growth restriction (≥32 weeks) general consensus is to use cerebral Doppler studies to influence surveillance and/or delivery timing. Fetal surveillance methods (most recommend cardiotocography) and recommended timing of delivery vary. There is universal agreement on the use of corticosteroids before birth at <34 weeks, and general consensus on the use of magnesium sulfate for neuroprotection in early-onset fetal growth restriction (<32 weeks). Most guidelines advise using cardiotocography surveillance to plan delivery in fetal growth restriction <32 weeks. The recommended gestation at delivery for fetal growth restriction with absent and reversed end-diastolic velocity varies from 32 to ≥34 weeks and 30 to ≥34 weeks, respectively. Overall, where there is high-quality evidence from randomized controlled trials and meta-analyses, eg, use of umbilical artery Doppler and corticosteroids for delivery <34 weeks, there is a high degree of consistency between national small-for-gestational-age guidelines. This review discusses areas where there is potential for convergence between small-for-gestational-age guidelines based on existing randomized controlled trials of management of small-for-gestational-age pregnancies, and areas of controversy. Research priorities include assessing the utility of late third-trimester scanning to prevent major morbidity and mortality and to investigate the optimum timing of delivery in fetuses with late-onset fetal growth restriction and abnormal Doppler parameters. Prospective studies are needed to compare new international population ultrasound standards with those in current use.

A Pathway to National Guidelines for Laboratory Diagnostics of Chronic Kidney Disease - Examples from Diverse European Countries

The principal benefit of guidelines is to improve the quality of care received by patients. In the 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (KDIGO) was released and it is designed to provide information and assist decision making. This review gives a brief overview of a various national CKD guidelines that rely on the newly released KDIGO guidelines. All of the included countries (France, Turkey, Norway and Croatia) are non-English speaking countries and they differ in population and socio economic aspects. Examples shown in this review may provide valuable experience for countries that are in process of creating their national CKD guidelines.

Identification and management of familial breast cancer in Austria

Aim The aim of this study is to review the legal implications, the technology, the indications and the management of women with a familial background of breast and/or ovarian cancer. Methods We have reviewed the literature and national Austrian guidelines to describe the uptake of genetic counseling and the management options offered in Austria. Results Genetic testing for the BRCA1 and 2 mutations is free and readily available through a nation-wide program. Increased awareness and the availability of screening programs and prophylactic surgery have resulted in a profound increase in genetic counseling and testing in women with a familial background of breast and ovarian cancer in Austria. Conclusion While readily available country-wide counseling has led to an increase in counseling and testing, Austrian legislation mandates "non-directional counseling" resulting in a comparatively low uptake of prophylactic surgery.

Acromioplasty in patients selected for operation by national guidelines

BACKGROUND

Shoulder impingement syndrome is the most common shoulder disorder. Even though conservative treatment is the primary treatment of choice, surgery has increased substantially in several countries during the last 20 years. This has resulted in recommended clinical guidelines for treatment of shoulder impingement syndrome in countries such as The Netherlands and Denmark during recent years. The aim of this study was to investigate the effectiveness of an arthroscopic subacromial decompression in 244 patients selected for surgery according to national clinical guidelines.

MATERIALS AND METHODS

Patients were included from an Internet-based shoulder and elbow database. They were asked to complete 2 questionnaires consisting of the Oxford Shoulder Score (OSS) and the EuroQol 5-Dimension 3-Level and visual analog scale preoperatively and at 6-month follow-up. All patients were carefully selected for surgery according to the national guidelines, with symptoms persisting for at least 6 months. Furthermore, subgroups related to the OSS were formed to assess the clinical outcome according to preoperative status and age.

RESULTS

For the complete study group, an OSS change of 10 (8.8-11.2; P = .0001) was found at 6-month follow-up. No significant difference was found between the genders (P = .17). The largest clinical effect from the intervention was found in the low preoperative OSS (pre-OSS) group, in which a mean change of 17 was found. The moderate and high pre-OSS groups had mean changes of 13 and 5, respectively. Similarly, according to the EuroQol 5-Dimension 3-Level and visual analog scale, the largest improvements were seen in the low and moderate pre-OSS groups.

CONCLUSION

Arthroscopic subacromial decompression is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish national guidelines.

Staff, associate specialist and specialty doctors' national audit on the management of gonorrhoea in the United Kingdom, 2015

The British Association for Sexual Health and HIV (BASHH) revised United Kingdom national guideline for the management of gonorrhoea in adults, 2011, identified five auditable outcome measures, namely, that all patients should receive first-line treatment, be screened or treated for chlamydial infection, have a test of cure (TOC), be offered written information and have partner notification carried out. The UK National Guideline for Gonorrhoea Testing, Clinical Effectiveness Group, BASHH, 2012, recommended in addition that all reactive nucleic acid amplification tests (NAATs) from pharynx and rectum should be confirmed by supplementary testing, using a second NAAT which detects a different nucleic acid target, all those with a positive NAAT for gonorrhoea should have culture and antimicrobial susceptibility testing and that TOC should be done by two weeks. Staff, associate specialist and specialty doctors performed a national audit against these standards. Data from 3233 cases were submitted; 8% of cases of gonorrhoea diagnosed in England, Scotland and Wales over this period. We found that 83% patients received first-line treatment with a reason for not doing so provided for 11%. TOC was documented for 62% and written information was offered to 41%. Results about supplementary testing were inconsistent. The results for the other outcomes were satisfactory.

Estimating Demand for and Supply of Pediatric Preventive Dental Care for Children and Identifying Dental Care Shortage Areas, Georgia, 2015

OBJECTIVES

Demand for dental care is expected to outpace supply through 2025. The objectives of this study were to determine the extent of pediatric dental care shortages in Georgia and to develop a general method for estimation that can be applied to other states.

METHODS

We estimated supply and demand for pediatric preventive dental care for the 159 counties in Georgia in 2015. We compared pediatric preventive dental care shortage areas (where demand exceeded twice the supply) designated by our methods with dental health professional shortage areas designated by the Health Resources & Services Administration. We estimated caries risk from a multivariate analysis of National Health and Nutrition Examination Survey data and national census data. We estimated county-level demand based on the time needed to perform preventive dental care services and the proportion of time that dentists spend on pediatric preventive dental care services from the Medical Expenditure Panel Survey.

RESULTS

Pediatric preventive dental care supply exceeded demand in Georgia in 75 counties: the average annual county-level pediatric preventive dental care demand was 16 866 hours, and the supply was 32 969 hours. We identified 41 counties as pediatric dental care shortage areas, 14 of which had not been designated by the Health Resources & Services Administration.

CONCLUSIONS

Age- and service-specific information on dental care shortage areas could result in more efficient provider staffing and geographic targeting.

[Treatment practice of acute cystitis on the basis of national prescription data]

INTRODUCTION

Urinary tract infections are one of the common diseases in the primary health care.

AIM

To analyse patterns of ambulatory antibiotic use in acute cystitis.

METHOD

Antibiotic use data was based on national-level prescription turnovers. Patterns of antibiotic use were evaluated by prescribing quality indicators. The content of different national guidelines for treatment of acute cystitis and adherence to these guidelines were also evaluated.

RESULTS

For the treatment of acute cystitis quinolones were used predominantly. Norfloxacin (26%) and ciprofloxacin (19%) were prescribed most commonly. The use of internationally recommended agents such as sulphonamides, nitrofurans and fosfomycin shared 15%, 7% and 2%, respectively. The average adherence rate to national guidelines was 66% and certain weak points (e.g. controversial content) of the national guidelines were also identified.

CONCLUSIONS

Antibiotic use in acute cystitis seems to be suboptimal in Hungary. Considering actual local antibiotic resistance patterns, a new national guideline should be worked out for acute cystitis treatment.

Conscientious care for the unconscious patient: new guidance from the Royal College of Physicians

Patients who remain unconscious and unaware after a brain insult challenge healthcare. Clinicians are faced with a clinical situation often outside their usual experience. Organisations are faced with practical issues concerning resource use. And people, especially family and friends, are faced with moral, legal and philosophical questions that have no easy answers. This conference launched national guidelines that should assist clinical teams and organisations, and should ensure that all patients and families receive a good quality service.

Early warning systems in the UK: variation in content and implementation strategy has implications for a NHS early warning system

The Royal College of Physicians report Acute medical care: the right person, in the right setting--first time advocates the introduction of a standardised NHS Early Warning Score (NEWS). Recommendations for the optimum scoring system have been released by NHS Quality Improvement Scotland (NHS QIS) and the National Institute for Health and Clinical Excellence (NICE). This study reviewed clinical practice in London and Scotland against national guidelines. All hospitals responsible for acute medical admissions completed a telephone survey (n = 25 London; n = 23 Scotland). All used an early warning system at point of entry to care. Eleven different systems were used in London and five in Scotland. Forty per cent of London hospitals and 70% of Scottish hospitals incorporated the minimum data set recommended by NICE. Overall, Scotland was closer to achieving standardisation. If NEWS is implemented, consideration of the NHS QIS approach may support a more consistent response.

Epidemiology of MRSA and current strategies in Europe and Japan

The prevalence of health-care associated infections caused by multi-drug resistant organisms has significantly increased over the past decade. Among these organisms, Methicillin-resistant Staphylococcus aureus (MRSA) plays a prominent and increasing role. Because of consequences for patients and the economic burden in course of prolonged treatment following MRSA infections and additional indirect costs for e.g. isolation or antiseptic treatment, this trend will further damage European health-care systems.

In 2006, a workshop was initiated at the 8^th International Congress of the German Society of Hospital Hygiene held in Berlin. The aim of this workshop was to give an overview of the current situation of MRSA in selected European countries and to elaborate on potential strategies to prevent MRSA-infections and dissemination. A questionnaire encompassing 20 questions addressed topics such as epidemiology, current measures and future prospects was distributed to representatives from various European countries and Japan. A variety of widely different answers was obtained. It was shown that in all countries prevalence of MRSA is on a rising tide. This trend is observable in all European countries, albeit less strong in The Netherlands, Slovenia, France, Austria and Scandinavian countries. It was conclude that prevention strategies in a united and expanding European Community will become of utmost importance and that rapid screening strategies, e.g. PCR, might be of assistance in such an approach. A potential strategy to improve infection control measures could be the requirement of health-insurance providers to sign contracts only with hospitals able to proof having an infection control management in place.

Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.