Screening for breast cancer

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC) and the U.S. Preventive Services Task Force (USPSTF): On December 4, 2009, the USPSTF unanimously voted to update the language of their recommendation regarding women under 50 years of age to clarify their original and continued intent. The following recommendations reflect that change.
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the Levels of Certainty regarding Net Benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.
Summary of Recommendations and Evidence

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. This is a B recommendation.
• The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. This is a C recommendation.
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. This is an I statement.
• The USPSTF recommends against teaching breast self-examination (BSE). This is a D recommendation.
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. This is an I statement.
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. This is an I statement.

Management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ

Recommendations

Major Recommendations

The ratings of the strength of recommendation (A-E), the quality of the evidence (I-III), and terminology used by the consensus conference (recommended, preferred, acceptable, unacceptable) are defined at the end of the Major Recommendations.
Note from the American Society for Colposcopy and Cervical Pathology (ASCCP): The management of low-grade cervical intraepithelial neoplasia (CIN) grade 1 has been modified significantly since 2001. Previously, management depended on whether colposcopy was satisfactory and treatment using ablative or excisional was acceptable for all women with CIN 1. In the new guidelines, cytological follow-up is the only recommended management option for women with CIN 1 who have low-grade referral cervical cytology, regardless of whether the colposcopic examination is satisfactory. Treatment is particularly discouraged in adolescents. The basic management of women in the general population with CIN 2,3 underwent only minor modifications, but options for the conservative management of adolescents with CIN 2,3 have been expanded. Moreover, management recommendations for women with biopsy-confirmed adenocarcinoma in situ are now included.

The management of erectile dysfunction

Recommendations

Major Recommendations

Definitions of the strength of the recommendations (standard, recommendation, option) are defined at the end of the "Major Recommendations" field.
Initial Management and Discussion of Treatment Options with Patients
Recommended Therapies and Patient Information
Standard: The management of erectile dysfunction begins with the identification of organic comorbidities and psychosexual dysfunctions; both should be appropriately treated or their care triaged. The currently available therapies that should be considered for the treatment of erectile dysfunction include the following: oral phosphodiesterase type 5 (PDE5) inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy (based on review of data and Panel consensus).
Standard: The patient and, when possible, his partner should be informed of the relevant treatment options and their associated risks and benefits. The choice of treatment should be made jointly by the physician, patient, and partner, when possible, taking into consideration patient preferences and expectations and the experience and judgment of the physician (based on Panel consensus).

Incontinence in women

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site for the most current version available.
Note from the National Guideline Clearinghouse (NGC) and the European Association of Urology (EAU): Following the complete updating for print in 2009 of the EAU Guidelines on Urinary Incontinence, the Incontinence Guidelines Writing Panel considered it helpful to provide an addendum to the Guidelines on the role of weight loss in urinary incontinence. Recent high-quality scientific publications underpin the statements made here. The new recommendation is labeled 2010 Addendum.
Levels of evidence (1a-4) and the grades of recommendations (A-C) are provided at the end of the "Major Recommendations" field.

Management of acute coronary syndromes

Recommendations

Major Recommendations

Notes from the National Guideline Clearinghouse (NGC)

• In March 2008, the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand released an addendum to their 2006 guidelines for the management of acute coronary syndrome, highlighting evidence "that strengthens the recommendations in the guidelines or provides alternatives to current recommended practice that should be considered based on the circumstances of the individual patient and setting." This new information is presented under the heading "2008 Addendum: Implications of the Findings."
• The National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand released an additional addendum in August 2011. This addendum "summarises clinical trial evidence published since 2007 that is relevant to the recommendations contained in the Heart Foundation's Guidelines for the management of acute coronary syndromes 2006 and 2007 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006. These recommendations are directed at the management of patients with spontaneous acute coronary syndromes, rather than those occurring as a result of other conditions (e.g., anaemia or thyrotoxicosis) where management may be directed at the underlying cause. This new information is presented under the heading "2011 Addendum."
• Definitions for the strength of recommendations and levels of evidence for the 2011 addendum are provided at the end of the "Major Recommendations" field.

Gonococcal infections

Description of Methods Used to Formulate the Recommendations

2010 Guideline
Centers for Disease Control and Prevention (CDC) staff members and invited consultants (including public- and private-sector professionals knowledgeable in the treatment of patients with sexually transmitted diseases [STDs]) assembled in Atlanta, Georgia, in April 2009, for a meeting where all evidence from the literature reviews pertaining to STD management was discussed.
Specifically, participants identified key questions regarding STD treatment that emerged from the literature reviews and discussed the information available to answer those questions. Discussion focused on four principal outcomes of STD therapy for each individual disease: 1) treatment of infection based on microbiologic eradication, 2) alleviation of signs and symptoms 3) prevention of sequelae, and 4) prevention of transmission. Cost-effectiveness and other advantages (e.g., single-dose formulations and directly observed therapy [DOT]) of specific regimens also were discussed. The consultants then assessed whether the questions identified were relevant, ranked them in order of priority, and answered the questions using the available evidence. In addition, the consultants evaluated the quality of evidence supporting the answers on the basis of the number, type, and quality of the studies.
2012 Addendum
During September–December 2011, CDC and five external Gonococcal Isolate Surveillance Project (GISP) principal investigators, each with Neisseria gonorrhoeae–specific expertise in surveillance, antimicrobial resistance, treatment, and antimicrobial susceptibility testing, reviewed antimicrobial susceptibility trends in GISP through August 2011 to determine whether to update CDC's current recommendations for treatment of uncomplicated gonorrhea.

Caregiving strategies for older adults with delirium, dementia and depression

Description of Methods Used to Formulate the Recommendations

June 2004 Guideline
In January of 2003, a panel of nurses and researchers with expertise in practice, education, and research related to gerontology and geriatric mental health care was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO). At the onset, the panel discussed and came to a consensus on the scope of the best practice guideline.
Following the extraction of identified recommendations and content from eight guidelines, the panel underwent a process of review, discussion, and consensus on the key evidence-based assessment criteria.
The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.

Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes

Description of Methods Used to Formulate the Recommendations

June 2004 Guideline
In January of 2003, a panel of nurses with expertise in practice and education related to diabetes, from institutional and community settings, was established by the Registered Nurses Association of Ontario (RNAO). At the onset, the panel discussed and came to consensus on the scope of the best practice guideline.
The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.

Prevention of post-lumbar puncture headaches

Major Recommendations

2000 Guideline
The quality of evidence ratings, I-III, and the strength of recommendations (Type A-Type E) are defined at the end of the "Major Recommendations" field.

1. Class I and Class II data in the anesthesiology literature and either Class I or Class II data in the neurology series show that smaller needle size is associated with reduced frequency of post-lumbar puncture headache (PLPHA) (Type A). The actual choice of needle size will be influenced by balancing other considerations, such as ease of use, the need to measure pressures, and the flow rate, with the desire to prevent PLPHA.
2. Class I data in the anesthesiology literature show that, when using a cutting needle, ensuring that the bevel direction is parallel to the dural fibers reduces the frequency of PLPHA. (Type A).
3. Class I data using a noncutting needle show that replacement of the stylet before the needle is withdrawn is associated with lower frequency of PLPHA. (Type A).
4. For spinal anesthesia, Class I data show that non-cutting needles reduce the frequency of PLPHA (Type A). However, for diagnostic lumbar punctures (LPs), the data are inconclusive.
5. Class I and Class II data have not demonstrated that the duration of recumbency following a diagnostic lumbar puncture influences the occurrence of PLPHA.
6. There is no evidence that the use of increased fluids prevents PLPHA.

Management of patients with ST-elevation myocardial infarction

Consensus guidelines for the management of women with abnormal cervical cancer screening tests

Recommended Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US)
General Management Approaches
A program of DNA testing for high-risk (oncogenic) types of HPV, repeat cervical cytologic testing, or colposcopy are all acceptable methods for managing women over the age of 20 years with ASC-US. (AI) When liquid-based cytology is used or when cocollection for HPV DNA testing can be done, "reflex" HPV DNA testing is the preferred approach. (AI)
Women with ASC-US who are HPV DNA negative can be followed up with repeat cytologic testing at 12 months. (BII) Women who are HPV DNA positive should be managed in the same fashion as women with LSIL and be referred for colposcopic evaluation. (AII) Endocervical sampling is preferred for women in whom no lesions are identified (BII) and those with an unsatisfactory colposcopy (AII) but is acceptable for women with a satisfactory colposcopy and a lesion identified in the transformation zone. (CII) Acceptable postcolposcopy management options of women with ASC-US who are HPV positive, but in whom cervical intraepithelial neoplasia (CIN) is not identified, are HPV DNA testing at 12 months or repeat cytological testing at 6 and 12 months. (BII) It is recommended that HPV DNA testing not be performed at intervals less than 12 months. (EIII)