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)