Most guideline organizations lack explicit guidance in how to incorporate cost considerations.

OBJECTIVES: Resource use and cost (RUC) evidence is one of the factors that can be considered when formulating recommendations in clinical practice guidelines (CPGs). However, it is unclear how CPG developers incorporate this information. The purpose of this study was to identify available guidance from guideline organizations on how to incorporate RUC in CPGs. STUDY DESIGN AND SETTING: This is a methodological survey. We searched MEDLINE, the G-I-N library, the Cochrane Methodology Register, and gray literature from inception to 2017. We included the most recent version of guidance documents. We excluded those that only reported methodology for adapting, endorsing, or updating CPGs, and documents reporting methods followed in the development of one or more specific CPGs. RESULTS: We included 77 documents from 67 organizations. Fifty-nine organizations (88.1%) include information regarding RUC during the CPG development process. Fifty-five (82.1%) organizations report taking RUC into account when developing recommendations: 44 (65.7%) do this explicitly, 5 (7.5%) implicitly, and 6 (9.0%) explicitly as optional. Twelve of the 44 organizations that explicitly consider RUC (27.3%) provide guidance to identify, assess and use the RUC evidence when developing recommendations. Twenty-three consider RUC when moving from the evidence to recommendations (52.3%). Seventeen of the 44 (38.6%) recommend making qualitative judgments about whether the desirable effects of interventions were worth the associated costs. CONCLUSION: More explicit guidance is needed alongside tools to help CPGs developers incorporate RUC evidence when formulating recommendations. Our results may be of use for guideline developers to improve this guidance.

Incorporating patients' views in guideline development: a systematic review of guidance documents.

OBJECTIVES: To assess how guidance documents for developing clinical guidelines (CGs) address the incorporation of patients' views in CGs. STUDY DESIGN AND SETTING: Systematic review to identify the methodology provided in guidance documents for incorporating (1) patients or representatives and (2) patients' views in the CG development process. The search was performed in 2017 in five databases. Two authors selected the studies, and data extraction was double-checked. RESULTS: We included guidance documents from 56 institutions. Of those, 40 (71.4%) recommended the inclusion of patients or their representatives, mainly for developing recommendations (14/40, 35.0%); reviewing the final version (13/40, 32.5%); formulating clinical questions (13/40, 32.5%); defining the scope and objectives (10/40, 25.0%); and dissemination and implementation (10/40, 25.0%). Concrete methods on how to incorporate patients were provided by 47.5% (19/40) of institutions. Forty (71.4%) institutions provided additional strategies to incorporate patients' views. The majority (30/40, 75.0%) suggested sources for obtaining these views (consultation with patients [24/40, 60.0%], using panels' judgment [10/40, 25.0%], conducting de novo research [10/40, 25.0%], or a systematic review [9/40, 22.5%]). CONCLUSION: Although most institutions suggest incorporating patients and their views when developing CGs, little detail is provided on how to do this. Institutions should provide more guidance as this could have a positive impact in guideline applicability.

Environmental contamination by multidrug-resistant microorganisms after daily cleaning.

We analyzed 91 samples of high-touch surfaces obtained within the first hour after daily cleaning in intensive care unit rooms occupied with patients with multidrug-resistant organisms (MDROs). We determined that 22% of high-touch surfaces in rooms with methicillin-resistant Staphylococcus aureus patients and 5% of high-touch surfaces in rooms with multiresistant Pseudomonas aeruginosa patients were colonized with the same strain as the patient. We postulated that textile cleaning wipes could be contaminated with MDROs and may contribute to its spreading within the room.

Are migrants health policies aimed at improving access to quality healthcare? An analysis of Spanish policies.

Although until April 2012, all Spanish citizens regardless of their origin, residence status and work situation were entitled to health care, available evidence suggested inadequate access for immigrants. Following the Aday and Andersen model, we conducted an analysis of policy elements that affect immigrants' access to health care in Spain, based on documentary analysis of national policies and selected regional policies related to migrant health care. Selected documents were (a) laws and plans in force at the time containing migrant health policies and (b) evaluations. The analysis included policy principles, objectives, strategies and evaluations. Results show that the national and regional policies analyzed are based on the principle that health care is a right granted to immigrants by law. These policies include strategies to facilitate access to health care, reducing barriers for entry to the system, for example simplifying requirements and raising awareness, but mostly they address the necessary qualities for services to be able to attend to a more diverse population, such as the adaptation of resources and programs, or improved communication and training. However, limited planning was identified in terms of their implementation, necessary resources and evaluation. In conclusion, the policies address relevant barriers of access for migrants and signal improvements in the health system's responsiveness, but reinforcement is required in order for them to be effectively implemented.

Impact of T3 thoracoscopic sympathectomy on pupillary function: a cause of partial Horner's syndrome?

BACKGROUND: Thoracoscopic bilateral sympathicolysis of the T3 sympathetic ganglia is an effective treatment for palmar hyperhidrosis, though not without potential complications and consequences such as Horner's syndrome. The objective of our study is to evaluate the repercussion of T3 sympathetic denervation on pupillary tone in patients with primary hyperhidrosis. METHODS: A prospective descriptive study of 25 patients (50 pupils) ranging in age from 18 to 40 years with an indication of T3 sympathectomy for palmar hyperhidrosis or palmar-plantar hyperhidrosis from 1 December 2009 to 31 December 2010 was carried out. We excluded all patients with previous eye surgery or other ocular pathologies and those with pathologies that contraindicate denervation surgery and ocular study. All patients were evaluated before surgery and at 24 h and 1 month after sympathetic denervation. Pupil/iris (P/I) ratio was measured before and after instillation of sympathicomimetic eye drops containing 1% apraclonidine. RESULTS: No statistically significant differences were found when we compared the preoperative P/I ratio of the left eyes versus the right eyes (P = 0.917). We found statistically significant differences (P < 0.001) between the preoperative P/I ratio [0.40 mm (standard deviation, SD 0.07 mm)] and the postoperative basal ratio [0.33 (SD 0.05)] at 24 h. The P/I ratio at 24 h increased from 0.33 to 0.36 (SD 0.09), a nonsignificant increase (P = 0.45), after instillation of medicated eye drops. No differences were observed between the preoperative [0.40 (SD 0.07)] and 1-month basal values [0.38 (SD 0.07)], and instillation of apraclonidine no longer induced a hypersensitivity response. CONCLUSIONS: T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis, even though this impairment is not generally evident on standard physical examination or reported by patients. This subclinical dysfunction may be caused by injury to an undefined group of presympathetic nerve cell axons in caudocranial direction that communicate with the cervical sympathetic ganglia and whose function is mydriatic pupillary innervation.