Keith B. Holten, MD

The authors report no financial relationships relevant to this article.

This article is adapted from the December 2008 installment of The Journal of Family Practice’s “Guideline Update” series. The Journal of Family Practice is an NLM-indexed publication of Quadrant HealthCom Inc., publisher of OBG Management.

• What are the critical steps in the assessment of a patient who suffers chronic pain?
• What are the four biologic mechanisms of pain?
• When is referral to a pain specialist recommended?

Answers to these questions are summarized below, and in the 2008 edition of Assessment and Management of Chronic Pain, a practice guideline developed and first published in 2005 by the Institute for Clinical Systems Improvement (ICSI), which also funded the work. ICSI is a collaboration of 57 medical groups sponsored by six Minnesota health plans. A third edition of the guideline, released in August 2008, summarizes current evidence about the assessment and treatment of chronic pain in mature adolescents (16 to 18 years old) and adults.

A distinct challenge to clinicians

Chronic pain—a persistent, life-altering condition—is one of the most challenging disorders for primary care physicians to treat. Unlike the case with acute pain, for which we seek to cure the underlying biologic condition, the goal of chronic pain management is to improve function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health-care team that includes specialists in behavioral health and physical rehabilitation—that is coordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle.

Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

The updated ICSI guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and nine appendices, also features two easy-to-use algorithms. One addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ).

Both algorithms identify Level-I and Level-II strategies that can be readily adapted to primary care practice. They are extremely helpful to physicians who are evaluating and developing a care plan for a patient who has chronic pain.

FIGURE 1 Chronic pain assessment

HIV, human immunodeficiency virus; ICSI, Institute for Clinical Systems Improvement; MS, multiple sclerosis.
*Pain types and contributing factors are not mutually exclusive. Patients frequently have more than one type of pain, as well as overlapping contributing factors.
Source: Institute for Clinical Systems Improvement. Reprinted with permission.

4 objectives

This latest guideline was developed to:

• improve the treatment of adult chronic-pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment)
• improve patients’ function by recommending development and use of a comprehensive treatment plan that includes a multispecialty team
• improve the use of Level-I and Level-II treatment approaches to chronic pain
• provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a seven-tier grading system to rate the evidence and a three-category system for the worksheets in the guideline appendices.

For this article, we converted evidence ratings in the guideline into so-called strength-of-recommendation taxonomy, or SORT.¹

What aspects of practice have changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example: The update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. (The previous version noted that medications were not the “primary” focus.)

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level-I versus Level-II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just in complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2 Chronic pain management
* DIRE, diagnosis, intractability, risk, efficacy.
Source: Institute for Clinical System Improvement. Reprinted with permission.

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management; most studies consider single-therapy management. An improvement, on the other hand, is that the evidence levels for each strategy are now listed within the section describing it—a notable change that makes it easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms walk clinicians through decision-making. In addition, the following nine appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source

As noted, the source document for this guideline is: Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July.

The complete guideline is available at: pain__chronic__assessment_and_management_of__guideline_.html " target="_blank"> http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/
pain__chronic__assessment_and_management_of__guideline_.html . (Accessed August 18, 2009.)

The authors report no financial relationships relevant to this article.

This article is adapted from the December 2008 installment of The Journal of Family Practice’s “Guideline Update” series. The Journal of Family Practice is an NLM-indexed publication of Quadrant HealthCom Inc., publisher of OBG Management.

• What are the critical steps in the assessment of a patient who suffers chronic pain?
• What are the four biologic mechanisms of pain?
• When is referral to a pain specialist recommended?

Answers to these questions are summarized below, and in the 2008 edition of Assessment and Management of Chronic Pain, a practice guideline developed and first published in 2005 by the Institute for Clinical Systems Improvement (ICSI), which also funded the work. ICSI is a collaboration of 57 medical groups sponsored by six Minnesota health plans. A third edition of the guideline, released in August 2008, summarizes current evidence about the assessment and treatment of chronic pain in mature adolescents (16 to 18 years old) and adults.

A distinct challenge to clinicians

Chronic pain—a persistent, life-altering condition—is one of the most challenging disorders for primary care physicians to treat. Unlike the case with acute pain, for which we seek to cure the underlying biologic condition, the goal of chronic pain management is to improve function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health-care team that includes specialists in behavioral health and physical rehabilitation—that is coordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle.

Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

The updated ICSI guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and nine appendices, also features two easy-to-use algorithms. One addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ).

Both algorithms identify Level-I and Level-II strategies that can be readily adapted to primary care practice. They are extremely helpful to physicians who are evaluating and developing a care plan for a patient who has chronic pain.

FIGURE 1 Chronic pain assessment

HIV, human immunodeficiency virus; ICSI, Institute for Clinical Systems Improvement; MS, multiple sclerosis.
*Pain types and contributing factors are not mutually exclusive. Patients frequently have more than one type of pain, as well as overlapping contributing factors.
Source: Institute for Clinical Systems Improvement. Reprinted with permission.

4 objectives

This latest guideline was developed to:

• improve the treatment of adult chronic-pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment)
• improve patients’ function by recommending development and use of a comprehensive treatment plan that includes a multispecialty team
• improve the use of Level-I and Level-II treatment approaches to chronic pain
• provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a seven-tier grading system to rate the evidence and a three-category system for the worksheets in the guideline appendices.

For this article, we converted evidence ratings in the guideline into so-called strength-of-recommendation taxonomy, or SORT.¹

What aspects of practice have changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example: The update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. (The previous version noted that medications were not the “primary” focus.)

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level-I versus Level-II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just in complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2 Chronic pain management
* DIRE, diagnosis, intractability, risk, efficacy.
Source: Institute for Clinical System Improvement. Reprinted with permission.

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management; most studies consider single-therapy management. An improvement, on the other hand, is that the evidence levels for each strategy are now listed within the section describing it—a notable change that makes it easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms walk clinicians through decision-making. In addition, the following nine appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source

As noted, the source document for this guideline is: Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July.

The complete guideline is available at: pain__chronic__assessment_and_management_of__guideline_.html " target="_blank"> http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/
pain__chronic__assessment_and_management_of__guideline_.html . (Accessed August 18, 2009.)

The authors report no financial relationships relevant to this article.

This article is adapted from the December 2008 installment of The Journal of Family Practice’s “Guideline Update” series. The Journal of Family Practice is an NLM-indexed publication of Quadrant HealthCom Inc., publisher of OBG Management.

• What are the critical steps in the assessment of a patient who suffers chronic pain?
• What are the four biologic mechanisms of pain?
• When is referral to a pain specialist recommended?

Answers to these questions are summarized below, and in the 2008 edition of Assessment and Management of Chronic Pain, a practice guideline developed and first published in 2005 by the Institute for Clinical Systems Improvement (ICSI), which also funded the work. ICSI is a collaboration of 57 medical groups sponsored by six Minnesota health plans. A third edition of the guideline, released in August 2008, summarizes current evidence about the assessment and treatment of chronic pain in mature adolescents (16 to 18 years old) and adults.

A distinct challenge to clinicians

Chronic pain—a persistent, life-altering condition—is one of the most challenging disorders for primary care physicians to treat. Unlike the case with acute pain, for which we seek to cure the underlying biologic condition, the goal of chronic pain management is to improve function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health-care team that includes specialists in behavioral health and physical rehabilitation—that is coordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle.

Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

The updated ICSI guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and nine appendices, also features two easy-to-use algorithms. One addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ).

Both algorithms identify Level-I and Level-II strategies that can be readily adapted to primary care practice. They are extremely helpful to physicians who are evaluating and developing a care plan for a patient who has chronic pain.

FIGURE 1 Chronic pain assessment

HIV, human immunodeficiency virus; ICSI, Institute for Clinical Systems Improvement; MS, multiple sclerosis.
*Pain types and contributing factors are not mutually exclusive. Patients frequently have more than one type of pain, as well as overlapping contributing factors.
Source: Institute for Clinical Systems Improvement. Reprinted with permission.

4 objectives

This latest guideline was developed to:

• improve the treatment of adult chronic-pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment)
• improve patients’ function by recommending development and use of a comprehensive treatment plan that includes a multispecialty team
• improve the use of Level-I and Level-II treatment approaches to chronic pain
• provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a seven-tier grading system to rate the evidence and a three-category system for the worksheets in the guideline appendices.

For this article, we converted evidence ratings in the guideline into so-called strength-of-recommendation taxonomy, or SORT.¹

What aspects of practice have changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example: The update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. (The previous version noted that medications were not the “primary” focus.)

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level-I versus Level-II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just in complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2 Chronic pain management
* DIRE, diagnosis, intractability, risk, efficacy.
Source: Institute for Clinical System Improvement. Reprinted with permission.

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management; most studies consider single-therapy management. An improvement, on the other hand, is that the evidence levels for each strategy are now listed within the section describing it—a notable change that makes it easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms walk clinicians through decision-making. In addition, the following nine appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source

As noted, the source document for this guideline is: Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July.

The complete guideline is available at: pain__chronic__assessment_and_management_of__guideline_.html " target="_blank"> http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/
pain__chronic__assessment_and_management_of__guideline_.html . (Accessed August 18, 2009.)

This guideline targets women who have had unprotected or inadequately protected intercourse within the past 120 hours and do not desire pregnancy.

Practitioners can make informed decisions about obstetric and gynecologic care, given the evidence in this guideline regarding safety, efficacy, risks and benefits of the use of emergency contraception including progestin-only and combined estrogen-progestin regimen.

The major outcome considered was incidence of unintended pregnancy. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

This guideline is extremely relevant in light of the recent decision (August 2006) by the US Food and Drug Administration to allow the Plan B (levonorgestrel) to be sold over the counter to women aged 18 and older.² It is still available by prescription to women aged <18 years.

Forty-nine percent of pregnancies were unintended in 2001. Of these 3.1 million unintended pregnancies, only 44% ended in births.³ Emergency contraception has an important role in reducing the number of unwanted pregnancies.

Lack of cost analysis weakened this guideline. Emergency contraceptive doses for commonly prescribed oral contraceptives are listed in the TABLE.

TABLE
Emergency contraception dosage for commonly prescribed oral contraceptives

Guideline development and evidence review

A search of the literature was performed using Medline, the Cochrane Library, and the American College of Obstetricians and Gynecologists’ own internal resources and documents. Restrictions included articles published in English between January 1985 and January 2005. Priority was given to meta-analyses and systematic reviews, which were analyzed by an expert panel. Recommendations were graded. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered.

Source for this guideline

American College of Obstetricians and Gynecologists (ACOG). Emergency contraception. ACOG practice bulletin no 69. Washington, DC: American College of Obstetricians and Gynecologists (ACOG); 2005. 10 p. [86 references]

Other guidelines

Emergency Contraception

This 2005 guideline published by the American Academy of Pediatrics is similar to the ACOG Guideline. It is comprehensive, but recommendations are not graded. The focus is on adolescent use of emergency contraception. It has an excellent section on telephone triage of sexually active teens prior to prescribing emergency contraception.

Source. American Academy of Pediatrics. Emergency contraception. Pediatrics 2005 Oct;116(4):1026-35. [101 references] Available at: aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1026.

Emergency Contraception

This 2003 Scottish guideline is well written, but lacks information about all current options for emergency contraception. It is strengthened by cost-effectiveness analysis.

Source. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Emergency contraception. Aberdeen, Scotland: Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit; 2003 Jun. 7 p. [53 references] Available at: www.ffprhc.org.uk/admin/uploads/EC%20revised%20PDF%2019.06.03.pdf.

Contraception and Family Planning: A guide to counseling and management

This 2005 guideline was published by Brigham and Women’s Hospital in Boston. In addition to emergency contraception, it provides recommendations on hormonal contraception (oral contraceptive pills, depo-medroxyprogesterone acetate, estrogen-progestin patches, vaginal ring, and levonorgestrel intrauterine), barrier contraception, intrauterine devices, surgical methods for contraception, and pregnancy termination.

Source. New Brigham and Women’s Hospital. Contraception and family planning. A guide to counseling and management. Boston, Mass: Brigham and Women’s Hospital; 2005.15 p. [6 references]. Available at: www.brighamandwomens.org/medical/handbookarticles/ContraceptionGuide.pdf.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

This guideline targets women who have had unprotected or inadequately protected intercourse within the past 120 hours and do not desire pregnancy.

Practitioners can make informed decisions about obstetric and gynecologic care, given the evidence in this guideline regarding safety, efficacy, risks and benefits of the use of emergency contraception including progestin-only and combined estrogen-progestin regimen.

The major outcome considered was incidence of unintended pregnancy. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

This guideline is extremely relevant in light of the recent decision (August 2006) by the US Food and Drug Administration to allow the Plan B (levonorgestrel) to be sold over the counter to women aged 18 and older.² It is still available by prescription to women aged <18 years.

Forty-nine percent of pregnancies were unintended in 2001. Of these 3.1 million unintended pregnancies, only 44% ended in births.³ Emergency contraception has an important role in reducing the number of unwanted pregnancies.

Lack of cost analysis weakened this guideline. Emergency contraceptive doses for commonly prescribed oral contraceptives are listed in the TABLE.

TABLE
Emergency contraception dosage for commonly prescribed oral contraceptives

Guideline development and evidence review

A search of the literature was performed using Medline, the Cochrane Library, and the American College of Obstetricians and Gynecologists’ own internal resources and documents. Restrictions included articles published in English between January 1985 and January 2005. Priority was given to meta-analyses and systematic reviews, which were analyzed by an expert panel. Recommendations were graded. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered.

Source for this guideline

American College of Obstetricians and Gynecologists (ACOG). Emergency contraception. ACOG practice bulletin no 69. Washington, DC: American College of Obstetricians and Gynecologists (ACOG); 2005. 10 p. [86 references]

Other guidelines

Emergency Contraception

This 2005 guideline published by the American Academy of Pediatrics is similar to the ACOG Guideline. It is comprehensive, but recommendations are not graded. The focus is on adolescent use of emergency contraception. It has an excellent section on telephone triage of sexually active teens prior to prescribing emergency contraception.

Source. American Academy of Pediatrics. Emergency contraception. Pediatrics 2005 Oct;116(4):1026-35. [101 references] Available at: aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1026.

Emergency Contraception

This 2003 Scottish guideline is well written, but lacks information about all current options for emergency contraception. It is strengthened by cost-effectiveness analysis.

Source. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Emergency contraception. Aberdeen, Scotland: Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit; 2003 Jun. 7 p. [53 references] Available at: www.ffprhc.org.uk/admin/uploads/EC%20revised%20PDF%2019.06.03.pdf.

Contraception and Family Planning: A guide to counseling and management

This 2005 guideline was published by Brigham and Women’s Hospital in Boston. In addition to emergency contraception, it provides recommendations on hormonal contraception (oral contraceptive pills, depo-medroxyprogesterone acetate, estrogen-progestin patches, vaginal ring, and levonorgestrel intrauterine), barrier contraception, intrauterine devices, surgical methods for contraception, and pregnancy termination.

Source. New Brigham and Women’s Hospital. Contraception and family planning. A guide to counseling and management. Boston, Mass: Brigham and Women’s Hospital; 2005.15 p. [6 references]. Available at: www.brighamandwomens.org/medical/handbookarticles/ContraceptionGuide.pdf.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

This guideline targets women who have had unprotected or inadequately protected intercourse within the past 120 hours and do not desire pregnancy.

Practitioners can make informed decisions about obstetric and gynecologic care, given the evidence in this guideline regarding safety, efficacy, risks and benefits of the use of emergency contraception including progestin-only and combined estrogen-progestin regimen.

The major outcome considered was incidence of unintended pregnancy. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

This guideline is extremely relevant in light of the recent decision (August 2006) by the US Food and Drug Administration to allow the Plan B (levonorgestrel) to be sold over the counter to women aged 18 and older.² It is still available by prescription to women aged <18 years.

Forty-nine percent of pregnancies were unintended in 2001. Of these 3.1 million unintended pregnancies, only 44% ended in births.³ Emergency contraception has an important role in reducing the number of unwanted pregnancies.

Lack of cost analysis weakened this guideline. Emergency contraceptive doses for commonly prescribed oral contraceptives are listed in the TABLE.

TABLE
Emergency contraception dosage for commonly prescribed oral contraceptives

Guideline development and evidence review

A search of the literature was performed using Medline, the Cochrane Library, and the American College of Obstetricians and Gynecologists’ own internal resources and documents. Restrictions included articles published in English between January 1985 and January 2005. Priority was given to meta-analyses and systematic reviews, which were analyzed by an expert panel. Recommendations were graded. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered.

Source for this guideline

American College of Obstetricians and Gynecologists (ACOG). Emergency contraception. ACOG practice bulletin no 69. Washington, DC: American College of Obstetricians and Gynecologists (ACOG); 2005. 10 p. [86 references]

Other guidelines

Emergency Contraception

This 2005 guideline published by the American Academy of Pediatrics is similar to the ACOG Guideline. It is comprehensive, but recommendations are not graded. The focus is on adolescent use of emergency contraception. It has an excellent section on telephone triage of sexually active teens prior to prescribing emergency contraception.

Source. American Academy of Pediatrics. Emergency contraception. Pediatrics 2005 Oct;116(4):1026-35. [101 references] Available at: aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1026.

Emergency Contraception

This 2003 Scottish guideline is well written, but lacks information about all current options for emergency contraception. It is strengthened by cost-effectiveness analysis.

Source. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Emergency contraception. Aberdeen, Scotland: Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit; 2003 Jun. 7 p. [53 references] Available at: www.ffprhc.org.uk/admin/uploads/EC%20revised%20PDF%2019.06.03.pdf.

Contraception and Family Planning: A guide to counseling and management

This 2005 guideline was published by Brigham and Women’s Hospital in Boston. In addition to emergency contraception, it provides recommendations on hormonal contraception (oral contraceptive pills, depo-medroxyprogesterone acetate, estrogen-progestin patches, vaginal ring, and levonorgestrel intrauterine), barrier contraception, intrauterine devices, surgical methods for contraception, and pregnancy termination.

Source. New Brigham and Women’s Hospital. Contraception and family planning. A guide to counseling and management. Boston, Mass: Brigham and Women’s Hospital; 2005.15 p. [6 references]. Available at: www.brighamandwomens.org/medical/handbookarticles/ContraceptionGuide.pdf.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

This feature reviews guidelines when they are developed with high-quality evidence and are relevant to primary care physicians. Now and then, however, it is instructive to critique recommendations that fall short of this mark. Four Parkinson’s disease practice parameters recently published by the American Academy of Neurology purport to be explicit, evidence-based, and of high quality; however, we feel these guidelines should be used with caution.

These recommendations for care of the Parkinson’s patient were published in Neurology as 4 separate reviews.^1-4 The topics covered include diagnosis and prognosis, treatment of motor fluctuations and dyskinesia, neuroprotective strategies, and evaluation and treatment of depression, psychosis, and dementia. There are 201 references. These recommendations were developed by the Quality Standards Subcommittee of the American Academy of Neurology. These guidelines can be accessed on the Web at: www.aan.com/professionals/practice/guideline/index.cfm.

Limitations of these recommendations

In these reviews, terminology regarding effectiveness is not consistently used. Instead of stating that a treatment “is effective,” the authors report that it “should be considered” or “should be offered.”

There is not consistency between the manuscripts. Abstracts in 2 of the publications^2,4 link level of evidence to the summary of recommendations in the abstracts. The other 2 do not.

In all 4 documents the abstracts are written in randomized controlled trial format, which make them difficult to quickly review. They are in question and answer format. There are long blocks of text without figures or tables to aid in learning and retaining the recommendations.

No cost-effectiveness analysis is performed in the reviews. They recommend that deep brain stimulation of the subthalamic nucleus “may be considered” to improve Parkinson’s disease symptoms and reduce medication use. But at what cost?

Because of their perspective from a specialty, these guidelines lack relevance for the family physician. For example, olfactory testing, which they recommend, is impractical for primary care physicians. However, no recommendations discuss dose titration with commonly prescribed medications. There are 3 pages reviewing surgical therapy.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

This feature reviews guidelines when they are developed with high-quality evidence and are relevant to primary care physicians. Now and then, however, it is instructive to critique recommendations that fall short of this mark. Four Parkinson’s disease practice parameters recently published by the American Academy of Neurology purport to be explicit, evidence-based, and of high quality; however, we feel these guidelines should be used with caution.

These recommendations for care of the Parkinson’s patient were published in Neurology as 4 separate reviews.^1-4 The topics covered include diagnosis and prognosis, treatment of motor fluctuations and dyskinesia, neuroprotective strategies, and evaluation and treatment of depression, psychosis, and dementia. There are 201 references. These recommendations were developed by the Quality Standards Subcommittee of the American Academy of Neurology. These guidelines can be accessed on the Web at: www.aan.com/professionals/practice/guideline/index.cfm.

Limitations of these recommendations

In these reviews, terminology regarding effectiveness is not consistently used. Instead of stating that a treatment “is effective,” the authors report that it “should be considered” or “should be offered.”

There is not consistency between the manuscripts. Abstracts in 2 of the publications^2,4 link level of evidence to the summary of recommendations in the abstracts. The other 2 do not.

In all 4 documents the abstracts are written in randomized controlled trial format, which make them difficult to quickly review. They are in question and answer format. There are long blocks of text without figures or tables to aid in learning and retaining the recommendations.

No cost-effectiveness analysis is performed in the reviews. They recommend that deep brain stimulation of the subthalamic nucleus “may be considered” to improve Parkinson’s disease symptoms and reduce medication use. But at what cost?

Because of their perspective from a specialty, these guidelines lack relevance for the family physician. For example, olfactory testing, which they recommend, is impractical for primary care physicians. However, no recommendations discuss dose titration with commonly prescribed medications. There are 3 pages reviewing surgical therapy.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

This feature reviews guidelines when they are developed with high-quality evidence and are relevant to primary care physicians. Now and then, however, it is instructive to critique recommendations that fall short of this mark. Four Parkinson’s disease practice parameters recently published by the American Academy of Neurology purport to be explicit, evidence-based, and of high quality; however, we feel these guidelines should be used with caution.

These recommendations for care of the Parkinson’s patient were published in Neurology as 4 separate reviews.^1-4 The topics covered include diagnosis and prognosis, treatment of motor fluctuations and dyskinesia, neuroprotective strategies, and evaluation and treatment of depression, psychosis, and dementia. There are 201 references. These recommendations were developed by the Quality Standards Subcommittee of the American Academy of Neurology. These guidelines can be accessed on the Web at: www.aan.com/professionals/practice/guideline/index.cfm.

Limitations of these recommendations

In these reviews, terminology regarding effectiveness is not consistently used. Instead of stating that a treatment “is effective,” the authors report that it “should be considered” or “should be offered.”

There is not consistency between the manuscripts. Abstracts in 2 of the publications^2,4 link level of evidence to the summary of recommendations in the abstracts. The other 2 do not.

In all 4 documents the abstracts are written in randomized controlled trial format, which make them difficult to quickly review. They are in question and answer format. There are long blocks of text without figures or tables to aid in learning and retaining the recommendations.

No cost-effectiveness analysis is performed in the reviews. They recommend that deep brain stimulation of the subthalamic nucleus “may be considered” to improve Parkinson’s disease symptoms and reduce medication use. But at what cost?

Because of their perspective from a specialty, these guidelines lack relevance for the family physician. For example, olfactory testing, which they recommend, is impractical for primary care physicians. However, no recommendations discuss dose titration with commonly prescribed medications. There are 3 pages reviewing surgical therapy.

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

What are the indications for carotid endarterectomy (CE) in the symptomatic patient?

How is symptomatic defined?

What are the indications for CE in the asymptomatic patient?

What is the role of aspirin therapy in these patients?

This guideline reviews the efficacy of carotid endarterectomy for stroke prevention in adults with symptomatic or asymptomatic internal carotid artery stenosis.

Symptomatic is defined as a cerebrovascular event in the carotid distribution (transient ischemic attack or nondisabling stroke) in the previous 6 months.

Indications for or against CE appear in the Practice Recommendations.

The evidence categories are assessment of therapeutic effectiveness, prevention, and risk assessment. Study outcomes considered are: benefits of carotid endarterectomy for symptomatic patients, benefits for asymptomatic patients, the efficacy within 24 hours in patients with progressing stroke, clinical variables that impact the risk/benefit ratio, the most important radiologic factors impacting the risk/benefit ratio, the ideal dose of aspirin preoperatively, the evidence/practice gap, the likelihood that trial results can be achieved in practice, the benefit of carotid endarterectomy concurrent with or prior to coronary artery bypass grafting, and the optimal time after stroke to perform the surgery. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Carotid endarterectomy has an important role in the prevention of stroke in patients with internal carotid artery stenosis, since the majority of strokes are ischemic. Strokes can be prevented if a high-grade internal carotid stenosis is corrected. More than 700,000 patients suffer a stroke each year in the US, with 80% related to ischemia (either thrombotic or embolic).² Most strokes occur after the age of 65, and the risk doubles each decade after the age of 55. Stroke is the third leading cause of death, with only heart disease and cancer killing more people. Strokes cause more serious long-term disabilities than any other illness. The guideline was weakened by lack of cost analysis.

Guideline development and evidence review

A literature search was performed using Ovid Medline for relevant articles published from 1990 to 2001 using the keywords carotid endarterectomy, carotid stenosis, carotid artery diseases, and clinical trials. The Cochrane Library statements on carotid endarterectomy for symptomatic and asymptomatic stenosis from 2004 were reviewed to confirm that additional relevant citations from 2002 to 2004 were identified.

The initial search yielded 1462 citations. This list was reduced by excluding case reports, letters to the editor, review articles without primary data, studies addressing carotid endarterectomy technical issues, case series from a single surgeon, and articles not written in English. Case series from a single institution were included. This narrowed the pertinent list to 186 articles, which were reviewed independently by 2 committee members. The committee also agreed that if a pooled analysis of the major symptomatic carotid endarterectomy studies or if the results of the Asymptomatic Carotid Surgery Trial were published prior to the completion of the committee’s manuscript, these would subsequently be reviewed.

Source for this guideline

Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy—an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794–801 [27 refs]. Available at: www.neurology.org/cgi/reprint/65/6/794.pdf.

Other guidelines on surgical management of carotid stenosis and stroke

Life after stroke: New Zealand guideline for management of stroke

This comprehensive 2003 guideline is written for New Zealand health care delivery system. It summarizes recommendations for the assessment and management of stroke, transient ischemic attacks, and intracerebral hemorrhage in various locales. The utility of carotid endarterectomy for secondary prevention is reviewed. The recommendations are comparable to the American Academy of Neurology.

Source. New Zealand Guidelines Group. Life after stroke. New Zealand guideline for management of stroke. Wellington, NZ: New Zealand Guidelines Group; 2003: 84 pp [164 refs]. Available at: www.nzgg.org.nz/guidelines/0037/Stroke_Summary.pdf.

What are the indications for carotid endarterectomy (CE) in the symptomatic patient?

How is symptomatic defined?

What are the indications for CE in the asymptomatic patient?

What is the role of aspirin therapy in these patients?

This guideline reviews the efficacy of carotid endarterectomy for stroke prevention in adults with symptomatic or asymptomatic internal carotid artery stenosis.

Symptomatic is defined as a cerebrovascular event in the carotid distribution (transient ischemic attack or nondisabling stroke) in the previous 6 months.

Indications for or against CE appear in the Practice Recommendations.

The evidence categories are assessment of therapeutic effectiveness, prevention, and risk assessment. Study outcomes considered are: benefits of carotid endarterectomy for symptomatic patients, benefits for asymptomatic patients, the efficacy within 24 hours in patients with progressing stroke, clinical variables that impact the risk/benefit ratio, the most important radiologic factors impacting the risk/benefit ratio, the ideal dose of aspirin preoperatively, the evidence/practice gap, the likelihood that trial results can be achieved in practice, the benefit of carotid endarterectomy concurrent with or prior to coronary artery bypass grafting, and the optimal time after stroke to perform the surgery. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Carotid endarterectomy has an important role in the prevention of stroke in patients with internal carotid artery stenosis, since the majority of strokes are ischemic. Strokes can be prevented if a high-grade internal carotid stenosis is corrected. More than 700,000 patients suffer a stroke each year in the US, with 80% related to ischemia (either thrombotic or embolic).² Most strokes occur after the age of 65, and the risk doubles each decade after the age of 55. Stroke is the third leading cause of death, with only heart disease and cancer killing more people. Strokes cause more serious long-term disabilities than any other illness. The guideline was weakened by lack of cost analysis.

Guideline development and evidence review

A literature search was performed using Ovid Medline for relevant articles published from 1990 to 2001 using the keywords carotid endarterectomy, carotid stenosis, carotid artery diseases, and clinical trials. The Cochrane Library statements on carotid endarterectomy for symptomatic and asymptomatic stenosis from 2004 were reviewed to confirm that additional relevant citations from 2002 to 2004 were identified.

The initial search yielded 1462 citations. This list was reduced by excluding case reports, letters to the editor, review articles without primary data, studies addressing carotid endarterectomy technical issues, case series from a single surgeon, and articles not written in English. Case series from a single institution were included. This narrowed the pertinent list to 186 articles, which were reviewed independently by 2 committee members. The committee also agreed that if a pooled analysis of the major symptomatic carotid endarterectomy studies or if the results of the Asymptomatic Carotid Surgery Trial were published prior to the completion of the committee’s manuscript, these would subsequently be reviewed.

Source for this guideline

Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy—an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794–801 [27 refs]. Available at: www.neurology.org/cgi/reprint/65/6/794.pdf.

Other guidelines on surgical management of carotid stenosis and stroke

Life after stroke: New Zealand guideline for management of stroke

This comprehensive 2003 guideline is written for New Zealand health care delivery system. It summarizes recommendations for the assessment and management of stroke, transient ischemic attacks, and intracerebral hemorrhage in various locales. The utility of carotid endarterectomy for secondary prevention is reviewed. The recommendations are comparable to the American Academy of Neurology.

Source. New Zealand Guidelines Group. Life after stroke. New Zealand guideline for management of stroke. Wellington, NZ: New Zealand Guidelines Group; 2003: 84 pp [164 refs]. Available at: www.nzgg.org.nz/guidelines/0037/Stroke_Summary.pdf.

What are the indications for carotid endarterectomy (CE) in the symptomatic patient?

How is symptomatic defined?

What are the indications for CE in the asymptomatic patient?

What is the role of aspirin therapy in these patients?

This guideline reviews the efficacy of carotid endarterectomy for stroke prevention in adults with symptomatic or asymptomatic internal carotid artery stenosis.

Symptomatic is defined as a cerebrovascular event in the carotid distribution (transient ischemic attack or nondisabling stroke) in the previous 6 months.

Indications for or against CE appear in the Practice Recommendations.

The evidence categories are assessment of therapeutic effectiveness, prevention, and risk assessment. Study outcomes considered are: benefits of carotid endarterectomy for symptomatic patients, benefits for asymptomatic patients, the efficacy within 24 hours in patients with progressing stroke, clinical variables that impact the risk/benefit ratio, the most important radiologic factors impacting the risk/benefit ratio, the ideal dose of aspirin preoperatively, the evidence/practice gap, the likelihood that trial results can be achieved in practice, the benefit of carotid endarterectomy concurrent with or prior to coronary artery bypass grafting, and the optimal time after stroke to perform the surgery. The evidence rating is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Carotid endarterectomy has an important role in the prevention of stroke in patients with internal carotid artery stenosis, since the majority of strokes are ischemic. Strokes can be prevented if a high-grade internal carotid stenosis is corrected. More than 700,000 patients suffer a stroke each year in the US, with 80% related to ischemia (either thrombotic or embolic).² Most strokes occur after the age of 65, and the risk doubles each decade after the age of 55. Stroke is the third leading cause of death, with only heart disease and cancer killing more people. Strokes cause more serious long-term disabilities than any other illness. The guideline was weakened by lack of cost analysis.

Guideline development and evidence review

A literature search was performed using Ovid Medline for relevant articles published from 1990 to 2001 using the keywords carotid endarterectomy, carotid stenosis, carotid artery diseases, and clinical trials. The Cochrane Library statements on carotid endarterectomy for symptomatic and asymptomatic stenosis from 2004 were reviewed to confirm that additional relevant citations from 2002 to 2004 were identified.

The initial search yielded 1462 citations. This list was reduced by excluding case reports, letters to the editor, review articles without primary data, studies addressing carotid endarterectomy technical issues, case series from a single surgeon, and articles not written in English. Case series from a single institution were included. This narrowed the pertinent list to 186 articles, which were reviewed independently by 2 committee members. The committee also agreed that if a pooled analysis of the major symptomatic carotid endarterectomy studies or if the results of the Asymptomatic Carotid Surgery Trial were published prior to the completion of the committee’s manuscript, these would subsequently be reviewed.

Source for this guideline

Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy—an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794–801 [27 refs]. Available at: www.neurology.org/cgi/reprint/65/6/794.pdf.

Other guidelines on surgical management of carotid stenosis and stroke

Life after stroke: New Zealand guideline for management of stroke

This comprehensive 2003 guideline is written for New Zealand health care delivery system. It summarizes recommendations for the assessment and management of stroke, transient ischemic attacks, and intracerebral hemorrhage in various locales. The utility of carotid endarterectomy for secondary prevention is reviewed. The recommendations are comparable to the American Academy of Neurology.

Source. New Zealand Guidelines Group. Life after stroke. New Zealand guideline for management of stroke. Wellington, NZ: New Zealand Guidelines Group; 2003: 84 pp [164 refs]. Available at: www.nzgg.org.nz/guidelines/0037/Stroke_Summary.pdf.

A Guideline Update¹ published in September 2003 summarized the Global Strategy for the management of chronic obstructive pulmonary disease (COPD).² The evidence in that report recommended against spirometry to “diagnose or assess severity of COPD.” However, the Agency for Healthcare Research and Quality (AHRQ) recently published new evidence³ that supports limited use of spirometry for assessing the condition of COPD patients.

AHRQ’s Minnesota Evidence-Based Practice Center reviewed articles published from 1966–2005. Pertinent studies assessed outcomes for adults in primary care settings who were at risk for COPD according to race, age, gender, tobacco use, symptoms, and spirometric status. Excluded from the review were children, persons with asthma, and those with alpha-1 antitrypsin deficiency. The 169-page report had 82 references. The evidence was not explicitly graded, which made it difficult to interpret the significance of each recommendation.

The authors cautioned against widespread spirometric testing of COPD patients. They cited expense of spirometry, resulting treatment costs, resource utilization expense, and personnel time. There is risk of labeling a large number of individuals as diseased who would not benefit from treatment.

CORRESPONDENCEKeith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

A Guideline Update¹ published in September 2003 summarized the Global Strategy for the management of chronic obstructive pulmonary disease (COPD).² The evidence in that report recommended against spirometry to “diagnose or assess severity of COPD.” However, the Agency for Healthcare Research and Quality (AHRQ) recently published new evidence³ that supports limited use of spirometry for assessing the condition of COPD patients.

AHRQ’s Minnesota Evidence-Based Practice Center reviewed articles published from 1966–2005. Pertinent studies assessed outcomes for adults in primary care settings who were at risk for COPD according to race, age, gender, tobacco use, symptoms, and spirometric status. Excluded from the review were children, persons with asthma, and those with alpha-1 antitrypsin deficiency. The 169-page report had 82 references. The evidence was not explicitly graded, which made it difficult to interpret the significance of each recommendation.

The authors cautioned against widespread spirometric testing of COPD patients. They cited expense of spirometry, resulting treatment costs, resource utilization expense, and personnel time. There is risk of labeling a large number of individuals as diseased who would not benefit from treatment.

CORRESPONDENCEKeith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

A Guideline Update¹ published in September 2003 summarized the Global Strategy for the management of chronic obstructive pulmonary disease (COPD).² The evidence in that report recommended against spirometry to “diagnose or assess severity of COPD.” However, the Agency for Healthcare Research and Quality (AHRQ) recently published new evidence³ that supports limited use of spirometry for assessing the condition of COPD patients.

AHRQ’s Minnesota Evidence-Based Practice Center reviewed articles published from 1966–2005. Pertinent studies assessed outcomes for adults in primary care settings who were at risk for COPD according to race, age, gender, tobacco use, symptoms, and spirometric status. Excluded from the review were children, persons with asthma, and those with alpha-1 antitrypsin deficiency. The 169-page report had 82 references. The evidence was not explicitly graded, which made it difficult to interpret the significance of each recommendation.

The authors cautioned against widespread spirometric testing of COPD patients. They cited expense of spirometry, resulting treatment costs, resource utilization expense, and personnel time. There is risk of labeling a large number of individuals as diseased who would not benefit from treatment.

CORRESPONDENCEKeith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

These questions are answered in the recommendations at right, derived from a guideline developed and funded by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. The target populations are infants and children with constipation who have no preexisting medical diagnosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Outcomes considered are 1) sensitivity and specificity of diagnostic tests; 2) rate of symptomatic relief; 3) prevention and control of symptoms; 4) medication and treatment side effects; 5) quality of life; and 6) bowel movement frequency. Recommendations were grouped by patient age: infants (age <1 year), children (age 1 year and older), and in general for all ages. Functional constipation was defined as fecal retention, unrelated to a medical or anatomic abnormality. Potential benefits and harms of implementing the guidelines were considered in the development. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Constipation is common among infants and children, accounting for 3% to 5% of visits to pediatric outpatient clinics. Males and females are equally affected.² In one study,³ 16% of parents reported constipation in their 2-year-olds.

A long bibliography accompanies this guideline, along with 77 references. The guideline is strengthened by inclusion of 2 algorithms for management of constipation in children aged <1 and >1 year, and consideration of potential harm. It was weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The constipation guideline committee first determined the scope of the guideline. A literature search in Medline from 1966 through 1997 was performed. These were filtered to include only randomized control trials. A second search strategy identified articles on treatment, including drug therapy, surgery, and “therapy.” In total, 160 articles were reviewed for development of the guideline. A systematic review of the literature was performed. Quality and strength of evidence were weighted according to a rating scheme.

The initial guideline was published in 1999. It was reviewed in 2004 and deemed current, after a new literature review and expert committee review.

Source for this guideline

Baker BB, Liptak GS, Colletti RB, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1999; 29:612–626.

Another similar guideline

Functional constipation and soiling in children

This 2003 guideline presents methods for diagnosis and treatment of functional constipation, associated with soiling in children. It is only pertinent for children with encopresis: voluntary or involuntary passage of formed, semiformed, or liquid stool in places other than the toilet.

Source. University of Michigan Health System. Functional constipation and soiling in children. Ann Arbor: University of Michigan Health System; 2003. 10 pp. [8 references]

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

These questions are answered in the recommendations at right, derived from a guideline developed and funded by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. The target populations are infants and children with constipation who have no preexisting medical diagnosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Outcomes considered are 1) sensitivity and specificity of diagnostic tests; 2) rate of symptomatic relief; 3) prevention and control of symptoms; 4) medication and treatment side effects; 5) quality of life; and 6) bowel movement frequency. Recommendations were grouped by patient age: infants (age <1 year), children (age 1 year and older), and in general for all ages. Functional constipation was defined as fecal retention, unrelated to a medical or anatomic abnormality. Potential benefits and harms of implementing the guidelines were considered in the development. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Constipation is common among infants and children, accounting for 3% to 5% of visits to pediatric outpatient clinics. Males and females are equally affected.² In one study,³ 16% of parents reported constipation in their 2-year-olds.

A long bibliography accompanies this guideline, along with 77 references. The guideline is strengthened by inclusion of 2 algorithms for management of constipation in children aged <1 and >1 year, and consideration of potential harm. It was weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The constipation guideline committee first determined the scope of the guideline. A literature search in Medline from 1966 through 1997 was performed. These were filtered to include only randomized control trials. A second search strategy identified articles on treatment, including drug therapy, surgery, and “therapy.” In total, 160 articles were reviewed for development of the guideline. A systematic review of the literature was performed. Quality and strength of evidence were weighted according to a rating scheme.

The initial guideline was published in 1999. It was reviewed in 2004 and deemed current, after a new literature review and expert committee review.

Source for this guideline

Baker BB, Liptak GS, Colletti RB, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1999; 29:612–626.

Another similar guideline

Functional constipation and soiling in children

This 2003 guideline presents methods for diagnosis and treatment of functional constipation, associated with soiling in children. It is only pertinent for children with encopresis: voluntary or involuntary passage of formed, semiformed, or liquid stool in places other than the toilet.

Source. University of Michigan Health System. Functional constipation and soiling in children. Ann Arbor: University of Michigan Health System; 2003. 10 pp. [8 references]

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

These questions are answered in the recommendations at right, derived from a guideline developed and funded by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. The target populations are infants and children with constipation who have no preexisting medical diagnosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Outcomes considered are 1) sensitivity and specificity of diagnostic tests; 2) rate of symptomatic relief; 3) prevention and control of symptoms; 4) medication and treatment side effects; 5) quality of life; and 6) bowel movement frequency. Recommendations were grouped by patient age: infants (age <1 year), children (age 1 year and older), and in general for all ages. Functional constipation was defined as fecal retention, unrelated to a medical or anatomic abnormality. Potential benefits and harms of implementing the guidelines were considered in the development. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Constipation is common among infants and children, accounting for 3% to 5% of visits to pediatric outpatient clinics. Males and females are equally affected.² In one study,³ 16% of parents reported constipation in their 2-year-olds.

A long bibliography accompanies this guideline, along with 77 references. The guideline is strengthened by inclusion of 2 algorithms for management of constipation in children aged <1 and >1 year, and consideration of potential harm. It was weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The constipation guideline committee first determined the scope of the guideline. A literature search in Medline from 1966 through 1997 was performed. These were filtered to include only randomized control trials. A second search strategy identified articles on treatment, including drug therapy, surgery, and “therapy.” In total, 160 articles were reviewed for development of the guideline. A systematic review of the literature was performed. Quality and strength of evidence were weighted according to a rating scheme.

The initial guideline was published in 1999. It was reviewed in 2004 and deemed current, after a new literature review and expert committee review.

Source for this guideline

Baker BB, Liptak GS, Colletti RB, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1999; 29:612–626.

Another similar guideline

Functional constipation and soiling in children

This 2003 guideline presents methods for diagnosis and treatment of functional constipation, associated with soiling in children. It is only pertinent for children with encopresis: voluntary or involuntary passage of formed, semiformed, or liquid stool in places other than the toilet.

Source. University of Michigan Health System. Functional constipation and soiling in children. Ann Arbor: University of Michigan Health System; 2003. 10 pp. [8 references]

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

Do topical steroids relieve atopic dermatitis?

What are the indications for pimecrolimus topical therapy?

Is ultraviolet phototherapy useful?

Are systemic corticosteroids indicated?

What is the role of immunomodulary therapies?

Children and adults with atopic dermatitis (eczema) are the target populations of a guideline that was recently funded and developed by the American Academy of Dermatology (AAD). The AAD Work Group and Guideline/Outcomes Task Force created the original document. The entire AAD membership was solicited for review and comment. The final recommendations were reviewed and approved by the AAD board of directors. The intended users are physicians.

The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) occurrence of atopic dermatitis; 2) therapeutic effectiveness, as measured by clinical signs and symptoms, blood cortisol levels, symptom scores, bacterial colonization, and serum immunoglobulin E (IgE) levels; and 3) adverse events. Their rating scheme has been updated to comply with the Strength of Recommendation taxonomy (SORT). ¹

Guideline relevance and limitations

Atopic dermatitis is a common problem encountered by family physicians. It typically manifests in infants aged 1 to 6 months; approximately 60% of patients experience their first outbreak by age 1 year and 90% by age 5 years. Onset of atopic dermatitis in adolescence or later is uncommon and should prompt consideration of another diagnosis.² Females usually have a worse prognosis than males.

A lengthy bibliography accompanies this guideline. The guideline is strengthened by use of summary tables and weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The work group was convened and the scope of the guideline was defined. They identified clinical questions to structure the primary issues in diagnosis and management. A literature search in Medline and EMBASE databases spanning the years 1990 to June 3, 2003, was performed. Additional searches were done by hand searching publications, including reviews, meta-analyses and correspondence.

The resultant prospective studies for treatments were screened for outcome evidence. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004; 50:391–404.

Other guidelines for atopic dermatitis

Guidelines for the evaluation of food allergies

This guideline from 2001 provides a rational approach to the evaluation of food allergies. Children with atopic dermatitis have a greater risk of food allergies. Allergy testing should be performed, when there is poor response to initial treatments.

Source. American Gastroenterological Association medical position statement: guidelines for the evaluation of food allergies. Gastroenterology 2001; 120:1023–1025.

Rhinitis

This guideline, revised in 2003, contains very little information about atopic dermatitis.

Source. Institute for Clinical Systems Improvement (ICSI). Rhinitis. Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2003 May. 34 p. [86 references]

Neonatal skin care

This guideline is mostly directed to routine skin care for infants and does not list separate special instructions for atopic dermatitis.

Source. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal Skin Care. Evidence-based Clinical Practice Guideline. Washington, DC: AWHONN; 2001. 54 p. [148 references]

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

Do topical steroids relieve atopic dermatitis?

What are the indications for pimecrolimus topical therapy?

Is ultraviolet phototherapy useful?

Are systemic corticosteroids indicated?

What is the role of immunomodulary therapies?

Children and adults with atopic dermatitis (eczema) are the target populations of a guideline that was recently funded and developed by the American Academy of Dermatology (AAD). The AAD Work Group and Guideline/Outcomes Task Force created the original document. The entire AAD membership was solicited for review and comment. The final recommendations were reviewed and approved by the AAD board of directors. The intended users are physicians.

The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) occurrence of atopic dermatitis; 2) therapeutic effectiveness, as measured by clinical signs and symptoms, blood cortisol levels, symptom scores, bacterial colonization, and serum immunoglobulin E (IgE) levels; and 3) adverse events. Their rating scheme has been updated to comply with the Strength of Recommendation taxonomy (SORT). ¹

Guideline relevance and limitations

Atopic dermatitis is a common problem encountered by family physicians. It typically manifests in infants aged 1 to 6 months; approximately 60% of patients experience their first outbreak by age 1 year and 90% by age 5 years. Onset of atopic dermatitis in adolescence or later is uncommon and should prompt consideration of another diagnosis.² Females usually have a worse prognosis than males.

A lengthy bibliography accompanies this guideline. The guideline is strengthened by use of summary tables and weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The work group was convened and the scope of the guideline was defined. They identified clinical questions to structure the primary issues in diagnosis and management. A literature search in Medline and EMBASE databases spanning the years 1990 to June 3, 2003, was performed. Additional searches were done by hand searching publications, including reviews, meta-analyses and correspondence.

The resultant prospective studies for treatments were screened for outcome evidence. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004; 50:391–404.

Other guidelines for atopic dermatitis

Guidelines for the evaluation of food allergies

This guideline from 2001 provides a rational approach to the evaluation of food allergies. Children with atopic dermatitis have a greater risk of food allergies. Allergy testing should be performed, when there is poor response to initial treatments.

Source. American Gastroenterological Association medical position statement: guidelines for the evaluation of food allergies. Gastroenterology 2001; 120:1023–1025.

Rhinitis

This guideline, revised in 2003, contains very little information about atopic dermatitis.

Source. Institute for Clinical Systems Improvement (ICSI). Rhinitis. Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2003 May. 34 p. [86 references]

Neonatal skin care

This guideline is mostly directed to routine skin care for infants and does not list separate special instructions for atopic dermatitis.

Source. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal Skin Care. Evidence-based Clinical Practice Guideline. Washington, DC: AWHONN; 2001. 54 p. [148 references]

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

Do topical steroids relieve atopic dermatitis?

What are the indications for pimecrolimus topical therapy?

Is ultraviolet phototherapy useful?

Are systemic corticosteroids indicated?

What is the role of immunomodulary therapies?

Children and adults with atopic dermatitis (eczema) are the target populations of a guideline that was recently funded and developed by the American Academy of Dermatology (AAD). The AAD Work Group and Guideline/Outcomes Task Force created the original document. The entire AAD membership was solicited for review and comment. The final recommendations were reviewed and approved by the AAD board of directors. The intended users are physicians.

The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) occurrence of atopic dermatitis; 2) therapeutic effectiveness, as measured by clinical signs and symptoms, blood cortisol levels, symptom scores, bacterial colonization, and serum immunoglobulin E (IgE) levels; and 3) adverse events. Their rating scheme has been updated to comply with the Strength of Recommendation taxonomy (SORT). ¹

Guideline relevance and limitations

Atopic dermatitis is a common problem encountered by family physicians. It typically manifests in infants aged 1 to 6 months; approximately 60% of patients experience their first outbreak by age 1 year and 90% by age 5 years. Onset of atopic dermatitis in adolescence or later is uncommon and should prompt consideration of another diagnosis.² Females usually have a worse prognosis than males.

A lengthy bibliography accompanies this guideline. The guideline is strengthened by use of summary tables and weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The work group was convened and the scope of the guideline was defined. They identified clinical questions to structure the primary issues in diagnosis and management. A literature search in Medline and EMBASE databases spanning the years 1990 to June 3, 2003, was performed. Additional searches were done by hand searching publications, including reviews, meta-analyses and correspondence.

The resultant prospective studies for treatments were screened for outcome evidence. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004; 50:391–404.

Other guidelines for atopic dermatitis

Guidelines for the evaluation of food allergies

This guideline from 2001 provides a rational approach to the evaluation of food allergies. Children with atopic dermatitis have a greater risk of food allergies. Allergy testing should be performed, when there is poor response to initial treatments.

Source. American Gastroenterological Association medical position statement: guidelines for the evaluation of food allergies. Gastroenterology 2001; 120:1023–1025.

Rhinitis

This guideline, revised in 2003, contains very little information about atopic dermatitis.

Source. Institute for Clinical Systems Improvement (ICSI). Rhinitis. Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2003 May. 34 p. [86 references]

Neonatal skin care

This guideline is mostly directed to routine skin care for infants and does not list separate special instructions for atopic dermatitis.

Source. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal Skin Care. Evidence-based Clinical Practice Guideline. Washington, DC: AWHONN; 2001. 54 p. [148 references]

CORRESPONDENCE
Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177. E-mail: [email protected]

Recommendations for these management issues are found in the guideline that was funded and developed by the American Academy of Neurology. Their Quality Standards Subcommittee, Practice Committee, and Board of Directors approved the recommendations. The target audience is physicians.

Patients with Bell’s palsy are the target population of this guideline. The objective is to summarize evidence regarding effectiveness of steroids, acyclovir, or surgical facial nerve decompression for improved functional outcomes in facial nerve palsy (Bell’s palsy). The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) relative rate and 95% confidence interval for goodreturn of facial function, and 2) relative rate and 95% confidence interval for completereturn of facial function. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Bell’s palsy results from damage to the 7th (facial) cranial nerve and affects 40,000 Americans each year. It is seen commonly in pregnant women and diabetics, as well as those with viral illnesses. Besides facial paralysis, other symptoms of Bell’s palsy may include pain, hypersensitivity to sound in the affected ear, and impairment of taste. The common cold sore viruses, herpes simplex virus, and other herpes viruses are the likely pathogens causing many cases of Bell’s palsy. The prognosis for Bell’s palsy is good and most patients get better within 2 weeks. Over 80% recover facial nerve function within 3 months.²

A lengthy bibliography accompanies the guideline. The guideline is weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The authors searched the National Library of Medicine’s Medline database from 1966 to June 2000. The resultant prospective studies for treatments with steroids, acyclovir, or surgery were screened for outcome evidence. There are 25 references. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:830–836.

Other guidelines on bell’s palsy

• Assessment: Neurologic risk of immunization. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

This older guideline refers to a few cases of Bell’s palsy associated with the plasma-derived hepatitis B vaccine used from 1982 to 1988. Since then the recombinant product has replaced the plasma-derived vaccine.

Source: Fenichel GM. Assessment: Neurologic risk of immunization: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology1999; 52:1546–1552. [30 references]

CORRECTION
The photographs in the Figure appearing in last month’s Clinical Inquiry, “Do routine eye exams reduce occurrence of blindness from type 2 dia-betes?” (page 733), were transposed. They appear correctly below.

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Recommendations for these management issues are found in the guideline that was funded and developed by the American Academy of Neurology. Their Quality Standards Subcommittee, Practice Committee, and Board of Directors approved the recommendations. The target audience is physicians.

Patients with Bell’s palsy are the target population of this guideline. The objective is to summarize evidence regarding effectiveness of steroids, acyclovir, or surgical facial nerve decompression for improved functional outcomes in facial nerve palsy (Bell’s palsy). The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) relative rate and 95% confidence interval for goodreturn of facial function, and 2) relative rate and 95% confidence interval for completereturn of facial function. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Bell’s palsy results from damage to the 7th (facial) cranial nerve and affects 40,000 Americans each year. It is seen commonly in pregnant women and diabetics, as well as those with viral illnesses. Besides facial paralysis, other symptoms of Bell’s palsy may include pain, hypersensitivity to sound in the affected ear, and impairment of taste. The common cold sore viruses, herpes simplex virus, and other herpes viruses are the likely pathogens causing many cases of Bell’s palsy. The prognosis for Bell’s palsy is good and most patients get better within 2 weeks. Over 80% recover facial nerve function within 3 months.²

A lengthy bibliography accompanies the guideline. The guideline is weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The authors searched the National Library of Medicine’s Medline database from 1966 to June 2000. The resultant prospective studies for treatments with steroids, acyclovir, or surgery were screened for outcome evidence. There are 25 references. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:830–836.

Other guidelines on bell’s palsy

• Assessment: Neurologic risk of immunization. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

This older guideline refers to a few cases of Bell’s palsy associated with the plasma-derived hepatitis B vaccine used from 1982 to 1988. Since then the recombinant product has replaced the plasma-derived vaccine.

Source: Fenichel GM. Assessment: Neurologic risk of immunization: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology1999; 52:1546–1552. [30 references]

CORRECTION
The photographs in the Figure appearing in last month’s Clinical Inquiry, “Do routine eye exams reduce occurrence of blindness from type 2 dia-betes?” (page 733), were transposed. They appear correctly below.

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Recommendations for these management issues are found in the guideline that was funded and developed by the American Academy of Neurology. Their Quality Standards Subcommittee, Practice Committee, and Board of Directors approved the recommendations. The target audience is physicians.

Patients with Bell’s palsy are the target population of this guideline. The objective is to summarize evidence regarding effectiveness of steroids, acyclovir, or surgical facial nerve decompression for improved functional outcomes in facial nerve palsy (Bell’s palsy). The evidence categories for this guideline are therapeutic effectiveness and treatment. Outcomes considered are 1) relative rate and 95% confidence interval for goodreturn of facial function, and 2) relative rate and 95% confidence interval for completereturn of facial function. The rating scheme is updated to comply with the SORT taxonomy.¹

Guideline relevance and limitations

Bell’s palsy results from damage to the 7th (facial) cranial nerve and affects 40,000 Americans each year. It is seen commonly in pregnant women and diabetics, as well as those with viral illnesses. Besides facial paralysis, other symptoms of Bell’s palsy may include pain, hypersensitivity to sound in the affected ear, and impairment of taste. The common cold sore viruses, herpes simplex virus, and other herpes viruses are the likely pathogens causing many cases of Bell’s palsy. The prognosis for Bell’s palsy is good and most patients get better within 2 weeks. Over 80% recover facial nerve function within 3 months.²

A lengthy bibliography accompanies the guideline. The guideline is weakened by lack of a cost-effectiveness analysis.

Guideline development and evidence review

The authors searched the National Library of Medicine’s Medline database from 1966 to June 2000. The resultant prospective studies for treatments with steroids, acyclovir, or surgery were screened for outcome evidence. There are 25 references. A meta-analysis of patient data and a systematic review of the evidence were performed. Quality and strength of evidence were weighted according to a rating scheme.

Source for this guideline

Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:830–836.

Other guidelines on bell’s palsy

• Assessment: Neurologic risk of immunization. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

This older guideline refers to a few cases of Bell’s palsy associated with the plasma-derived hepatitis B vaccine used from 1982 to 1988. Since then the recombinant product has replaced the plasma-derived vaccine.

Source: Fenichel GM. Assessment: Neurologic risk of immunization: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology1999; 52:1546–1552. [30 references]

CORRECTION
The photographs in the Figure appearing in last month’s Clinical Inquiry, “Do routine eye exams reduce occurrence of blindness from type 2 dia-betes?” (page 733), were transposed. They appear correctly below.

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Recommendations for these management issues are found in the guideline developed in a joint effort of the American College of Physicians Clinical Efficacy Assessment Subcommittee and the American Academy of Family Physicians Commission on Clinical Policies and Research. It was funded by both organizations and approved by their Boards before publication. The target audience is internists and family physicians.

The target patients are adults with newly diagnosed atrial fibrillation. The guideline does not apply to postoperative patients, post-myocardial infarction patients, those with class IV heart failure or valvular heart disease, or patients taking antiarrhythmic medications.

The objective of this guideline is to recommend pharmacologic management of newly diagnosed atrial fibrillation. The evidence category for this guideline is management. Outcomes considered are control of heart rate and stroke risk reduction. The committees used the Guyatt method of grading recommendations,¹ a qualitative approach to the literature. These were revised to comply with the SORT taxonomy.²

Guideline relevance and limitations

Atrial fibrillation is common, affecting anywhere from 1% of the American population at age 60 to 8% at age 80. It is more common in men than women. Even if patients are asymptomatic, they are at increased risk of stroke (1.9%–18% per year).

A lengthy bibliography accompanies the guideline. Tables of supporting evidence are lacking, which makes it more difficult to analyze the final recommendations. The guideline is weakened by the lack of a cost-effectiveness analysis.

Guideline development and evidence review

This guideline is based on background papers published by McNamara³ and the John Hopkins Evidence-Based Practice Center⁴ under contract with the Agency for Healthcare Research and Quality. There are 57 references.

The guideline group reviewed the evidence and made graded recommendations regarding rate control versus rhythm control, stroke prevention and anticoagulation, electrical conversion versus pharmacologic conversion, the role of transesophageal echocardiography in guiding therapy, and maintenance therapy.

Source for this guideline

Snow V, Weiss KB, LeFevre M, et al.Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139: 1009–1017.

Other guidelines on atrial fibrillation

ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation.

A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation).

This 2001 guideline is the work of an international panel. Algorithms are provided for pharma-cologic management of patients with newly diagnosed atrial fibrillation, pharmacologic management of patients with recurrent paroxysmal atrial fibrillation, antiarrythmic drug therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation, and pharmacologic management of patients with recurrent persistent or permanent atrial fibrillation. Recent evidence regarding rate control versus rhythm control was not available at publication of this guideline.

Sources: American College of Cardiology, American Heart Association, European Society of Cardiology. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol 2001; 38:1266i–lxx. (580 references) Fuster V, Ryden LE, Asinger RW, et al.ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology. Eur Heart J 2001; 22:1852–1923. (580 references)

Antithrombotic therapy in atrial fibrillation.

In: Sixth ACCP Consensus Conference on Antithrombotic Therapy.

This is an excellent review of a grading scheme for stroke risk and choice of anti-thrombotic agents.

Source: Albers GW, Dalen JE, Laupacis A, et al.Antithrombotic therapy in atrial fibrillation. Chest 2001; 119(1 Suppl):194S–206S. (103 references)

Atrial fibrillation: drug treatment and electric cardioversion.

This Finnish guideline makes recommendations regarding drug treatment, anticoagulation, and cardioversion for patients with atrial fibrillation and atrial flutter. The recommendations are not graded.

Source: Finnish Medical Society Duodecim. Atrial Fibrillation: Drug Treatment and Electric Cardioversion. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 Mar 4. Various pages.

Preventive health care, 2000 update.

Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke.

This guideline is from 2000 and found insufficient evidence to recommend for or against ambulatory electrocardiography to detect atrial fibrillation for patients after stroke or TIA.

Source: Bell C, Kapral M. Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Canadian Task Force on Preventive Health Care. Can J Neurol Sc. 2000; 27:25–31. (78 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Recommendations for these management issues are found in the guideline developed in a joint effort of the American College of Physicians Clinical Efficacy Assessment Subcommittee and the American Academy of Family Physicians Commission on Clinical Policies and Research. It was funded by both organizations and approved by their Boards before publication. The target audience is internists and family physicians.

The target patients are adults with newly diagnosed atrial fibrillation. The guideline does not apply to postoperative patients, post-myocardial infarction patients, those with class IV heart failure or valvular heart disease, or patients taking antiarrhythmic medications.

The objective of this guideline is to recommend pharmacologic management of newly diagnosed atrial fibrillation. The evidence category for this guideline is management. Outcomes considered are control of heart rate and stroke risk reduction. The committees used the Guyatt method of grading recommendations,¹ a qualitative approach to the literature. These were revised to comply with the SORT taxonomy.²

Guideline relevance and limitations

Atrial fibrillation is common, affecting anywhere from 1% of the American population at age 60 to 8% at age 80. It is more common in men than women. Even if patients are asymptomatic, they are at increased risk of stroke (1.9%–18% per year).

A lengthy bibliography accompanies the guideline. Tables of supporting evidence are lacking, which makes it more difficult to analyze the final recommendations. The guideline is weakened by the lack of a cost-effectiveness analysis.

Guideline development and evidence review

This guideline is based on background papers published by McNamara³ and the John Hopkins Evidence-Based Practice Center⁴ under contract with the Agency for Healthcare Research and Quality. There are 57 references.

The guideline group reviewed the evidence and made graded recommendations regarding rate control versus rhythm control, stroke prevention and anticoagulation, electrical conversion versus pharmacologic conversion, the role of transesophageal echocardiography in guiding therapy, and maintenance therapy.

Source for this guideline

Snow V, Weiss KB, LeFevre M, et al.Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139: 1009–1017.

Other guidelines on atrial fibrillation

ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation.

A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation).

This 2001 guideline is the work of an international panel. Algorithms are provided for pharma-cologic management of patients with newly diagnosed atrial fibrillation, pharmacologic management of patients with recurrent paroxysmal atrial fibrillation, antiarrythmic drug therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation, and pharmacologic management of patients with recurrent persistent or permanent atrial fibrillation. Recent evidence regarding rate control versus rhythm control was not available at publication of this guideline.

Sources: American College of Cardiology, American Heart Association, European Society of Cardiology. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol 2001; 38:1266i–lxx. (580 references) Fuster V, Ryden LE, Asinger RW, et al.ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology. Eur Heart J 2001; 22:1852–1923. (580 references)

Antithrombotic therapy in atrial fibrillation.

In: Sixth ACCP Consensus Conference on Antithrombotic Therapy.

This is an excellent review of a grading scheme for stroke risk and choice of anti-thrombotic agents.

Source: Albers GW, Dalen JE, Laupacis A, et al.Antithrombotic therapy in atrial fibrillation. Chest 2001; 119(1 Suppl):194S–206S. (103 references)

Atrial fibrillation: drug treatment and electric cardioversion.

This Finnish guideline makes recommendations regarding drug treatment, anticoagulation, and cardioversion for patients with atrial fibrillation and atrial flutter. The recommendations are not graded.

Source: Finnish Medical Society Duodecim. Atrial Fibrillation: Drug Treatment and Electric Cardioversion. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 Mar 4. Various pages.

Preventive health care, 2000 update.

Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke.

This guideline is from 2000 and found insufficient evidence to recommend for or against ambulatory electrocardiography to detect atrial fibrillation for patients after stroke or TIA.

Source: Bell C, Kapral M. Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Canadian Task Force on Preventive Health Care. Can J Neurol Sc. 2000; 27:25–31. (78 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Recommendations for these management issues are found in the guideline developed in a joint effort of the American College of Physicians Clinical Efficacy Assessment Subcommittee and the American Academy of Family Physicians Commission on Clinical Policies and Research. It was funded by both organizations and approved by their Boards before publication. The target audience is internists and family physicians.

The target patients are adults with newly diagnosed atrial fibrillation. The guideline does not apply to postoperative patients, post-myocardial infarction patients, those with class IV heart failure or valvular heart disease, or patients taking antiarrhythmic medications.

The objective of this guideline is to recommend pharmacologic management of newly diagnosed atrial fibrillation. The evidence category for this guideline is management. Outcomes considered are control of heart rate and stroke risk reduction. The committees used the Guyatt method of grading recommendations,¹ a qualitative approach to the literature. These were revised to comply with the SORT taxonomy.²

Guideline relevance and limitations

Atrial fibrillation is common, affecting anywhere from 1% of the American population at age 60 to 8% at age 80. It is more common in men than women. Even if patients are asymptomatic, they are at increased risk of stroke (1.9%–18% per year).

A lengthy bibliography accompanies the guideline. Tables of supporting evidence are lacking, which makes it more difficult to analyze the final recommendations. The guideline is weakened by the lack of a cost-effectiveness analysis.

Guideline development and evidence review

This guideline is based on background papers published by McNamara³ and the John Hopkins Evidence-Based Practice Center⁴ under contract with the Agency for Healthcare Research and Quality. There are 57 references.

The guideline group reviewed the evidence and made graded recommendations regarding rate control versus rhythm control, stroke prevention and anticoagulation, electrical conversion versus pharmacologic conversion, the role of transesophageal echocardiography in guiding therapy, and maintenance therapy.

Source for this guideline

Snow V, Weiss KB, LeFevre M, et al.Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139: 1009–1017.

Other guidelines on atrial fibrillation

ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation.

A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation).

This 2001 guideline is the work of an international panel. Algorithms are provided for pharma-cologic management of patients with newly diagnosed atrial fibrillation, pharmacologic management of patients with recurrent paroxysmal atrial fibrillation, antiarrythmic drug therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation, and pharmacologic management of patients with recurrent persistent or permanent atrial fibrillation. Recent evidence regarding rate control versus rhythm control was not available at publication of this guideline.

Sources: American College of Cardiology, American Heart Association, European Society of Cardiology. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol 2001; 38:1266i–lxx. (580 references) Fuster V, Ryden LE, Asinger RW, et al.ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology. Eur Heart J 2001; 22:1852–1923. (580 references)

Antithrombotic therapy in atrial fibrillation.

In: Sixth ACCP Consensus Conference on Antithrombotic Therapy.

This is an excellent review of a grading scheme for stroke risk and choice of anti-thrombotic agents.

Source: Albers GW, Dalen JE, Laupacis A, et al.Antithrombotic therapy in atrial fibrillation. Chest 2001; 119(1 Suppl):194S–206S. (103 references)

Atrial fibrillation: drug treatment and electric cardioversion.

This Finnish guideline makes recommendations regarding drug treatment, anticoagulation, and cardioversion for patients with atrial fibrillation and atrial flutter. The recommendations are not graded.

Source: Finnish Medical Society Duodecim. Atrial Fibrillation: Drug Treatment and Electric Cardioversion. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 Mar 4. Various pages.

Preventive health care, 2000 update.

Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke.

This guideline is from 2000 and found insufficient evidence to recommend for or against ambulatory electrocardiography to detect atrial fibrillation for patients after stroke or TIA.

Source: Bell C, Kapral M. Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Canadian Task Force on Preventive Health Care. Can J Neurol Sc. 2000; 27:25–31. (78 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].