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1.
Z Geburtshilfe Neonatol ; 223(6): 373-394, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31801169

RESUMO

AIMS: This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. METHODS: The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). RECOMMENDATIONS: Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.


Assuntos
Ruptura Prematura de Membranas Fetais , Trabalho de Parto Prematuro/prevenção & controle , Guias de Prática Clínica como Assunto , Nascimento Prematuro , Sociedades Médicas , Prevenção Terciária , Incompetência do Colo do Útero , Áustria , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Humanos , Recém-Nascido , Obstetrícia , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Sistema de Registros
2.
Ann Am Thorac Soc ; 16(12): 1463-1472, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31774323

RESUMO

Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS's work in performance measure development and guideline implementation. To illustrate the application of the ATS's performance measure development framework, we used the example of a low-tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing "preliminary performance measures" and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS's guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.

3.
Z Evid Fortbild Qual Gesundhwes ; 147-148: 45-57, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31718988

RESUMO

BACKGROUND: Evidence-based and formally consensus-based clinical practice guidelines (CPGs) offer potential for the development of quality indicators (QIs). Although QIs are recommended as part of some CPGs, there is no accepted gold standard for the specific development process of guideline-based QIs. The purpose of this review, which is embedded in a mixed-methods research project, was to analyze the current state of methodological approaches for QI development in German CPGs to derive insights for the development of a national evidence-guided and consensus-based standard for guideline-based development of QIs. METHODS: In order to identify valid CPGs containing recommendations for QIs, a search was carried out (July 31, 2016) via the guideline database of the German Association of the Scientific Medical Societies (AWMF). Based on a stratified random sample per guideline program (guidelines published by medical societies, National Program for Disease Management Guidelines (DMG), and the German Guideline Program in Oncology [GGPO]), 11 CPGs were selected. With regard to QIs, the specific development methodology, indications on their psychometric properties and how the quality of care should be examined by recommended QIs were extracted and compared by using the guideline documents. RESULTS: In 35 of the 109 (16/85 medical societies, 4/8 DMG, 15/16 GGPO) (32 %) valid CPGs, a total of 372 QIs were recommended. Based on 11 randomly selected guidelines (5 published by medical societies, 1 DMG, 5 GGPO; a total of 109 QIs), the QI development methodology was inconsistent in all five medical societies guidelines (including QI presentation, usage and selection of guideline recommendations for QI derivation) compared to DMG and GGPO. Based on all 109 QIs, 2 (2 %) were presented as a quantitative measure with a reference range, and quality objectives were formulated for 17 (16 %). There was no guideline explicitly reporting about the results of a pilot study or data-based analysis of the psychometric properties of the recommended QIs. The GGPO guideline documents were the only ones providing information on the assessment of the quality of care based on recommended QIs. DISCUSSION: The usage of the QI manuals of the DMG and GGPO leads to a largely standardized development of guideline-based QIs. In the CPGs of the medical societies - if at all - QIs are developed inconsistently and mostly unsystematically. Due to largely missing reference ranges and quality objectives, the identified QIs cannot yet be used to transparently identify potential quality deficits in health care. This requires results of pilot studies and further development of guideline-based QI. CONCLUSIONS: A standard for QI development is needed for German guideline authors to seize the opportunity and develop clinically relevant, widely accepted and evidence-based QIs in the guideline development process. In addition, it must be ensured that appropriate structures are used or set up in order to be able to apply the recommended QIs in the German healthcare system.


Assuntos
Assistência à Saúde , Guias de Prática Clínica como Assunto , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde , Prática Clínica Baseada em Evidências , Alemanha , Humanos , Projetos Piloto
4.
Z Evid Fortbild Qual Gesundhwes ; 147-148: 34-44, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31732386

RESUMO

BACKGROUND: Evidence-based and formally consensus-based clinical practice guidelines (S3-CPGs) are a valuable source for the development of quality indicators (QIs) in Germany. While deriving QIs from guideline recommendations is a mandatory part of the development of S3-CPGs within the National Program for Disease Management Guidelines (DMGP) and the German Guideline Program in Oncology (GGPO), there is no such obligation in the guideline program of the Association of the Scientific Medical Societies in Germany (AWMF) (MS program). Despite that, several S3-CPGs in the MS program have been published with QIs in the last years while some DMGP and one GGPO S3 guidelines have failed to meet this requirement. From the perspective of the guideline authors of all three mentioned programs, the present qualitative study examined why S3-CPGs do or do not contain QIs and explored the factors perceived by authors as either facilitating or hampering in the QI development process. METHODS: Semi-structured interviews were conducted with authors of 22 S3-CPGs, 11 of which represented guidelines containing QIs and 11 of which represented guidelines without QIs. Authors of guidelines containing QIs (n=11) were asked about the perceived decisive reasons for formulating QIs and about facilitators and barriers during the QI development process. Authors of guidelines without QIs (n=11) gave reasons for not formulating QIs. Interviews were analyzed using structuring qualitative content analysis. RESULTS: Within the MS program, not formulating QIs was mainly attributed to the lack of a mandatory requirement and to insufficient funding of guideline projects. Amongst DMGP authors, a low priority of QI development prevailed, which was, for example, due to already existing QIs or to their lacking implementation. In the GGPO guideline examined, not formulating QIs was due to the guideline topic (prevention) - for this topic, there was a lack of suitable evidence and data sources. If QIs were developed, the most important facilitating factor in the development process, across all programs, was the methodological support provided by the guideline program. Important hampering factors included the additional time required for QI development and concerns regarding the implementation of many potential QIs, especially due to a lack of data availability. DISCUSSION: For regular development of QIs within S3-CPG projects, the incorporation of such a requirement in the guideline program is a necessary, but not a sufficient, condition. Other pivotal factors include systematic methodological support, adequate financial and staff resources and the perceived meaningfulness and relevance of guideline-based QI development, measured in terms of the actual implementation of already existing QIs. CONCLUSION: The study reveals starting points for measures to strengthen the consideration of QI development in German S3-CPG projects, especially within the MS program. Without substantial structural changes, especially of the resources of guideline groups, and without an overall concept covering the entire process from QI development to QI implementation, guideline-based QI development will remain heavily dependent on the (self-)motivation of guideline groups.


Assuntos
Recursos em Saúde , Guias de Prática Clínica como Assunto/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Sociedades Médicas , Protocolos Clínicos/normas , Assistência à Saúde/normas , Alemanha , Humanos , Oncologia , Pesquisa Qualitativa
5.
Z Geburtshilfe Neonatol ; 223(5): 304-316, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31623006

RESUMO

AIMS: This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recent scientific literature, the experience of the members of the guideline commission and the views of self-help groups. METHODS: Based on the international literature, the members of the participating medical societies and organizations developed Recommendations and Statements. These were adopted following a formal process (structured consensus conference with neutral moderation, voting was done in writing using the Delphi method to achieve consensus). RECOMMENDATIONS: Part I of this short version of the guideline lists Statements and Recommendations on the epidemiology, etiology, prediction and primary and secondary prevention of preterm birth.


Assuntos
Guias de Prática Clínica como Assunto , Nascimento Prematuro , Áustria , Feminino , Humanos , Recém-Nascido , Gravidez , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , Prevenção Primária , Sistema de Registros , Prevenção Secundária , Sociedades Médicas
6.
Respiration ; 98(4): 357-372, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31505511

RESUMO

For patients with acute respiratory insufficiency, mechanical ("invasive") ventilation is a fundamental therapeutic measure to ensure sufficient gas exchange. Despite decades of strong research efforts, central questions on mechanical ventilation therapy are still answered incompletely. Therefore, many different ventilation modes and settings have been used in daily clinical practice without scientifically sound bases. At the same time, implementation of the few evidence-based therapeutic concepts (e.g., "lung protective ventilation") into clinical practice is still insufficient. The aim of our guideline project "Mechanical ventilation and extracorporeal gas exchange in acute respiratory insufficiency" was to develop an evidence-based decision aid for treating patients with and on mechanical ventilation. It covers the whole pathway of invasively ventilated patients (including indications of mechanical ventilation, ventilator settings, additional and rescue therapies, and liberation from mechanical ventilation). To assess the quality of scientific evidence and subsequently derive recommendations, we applied the Grading of Recommendations, Assessment, Development and Evaluation method. For the first time, using this globally accepted methodological standard, our guideline contains recommendations on mechanical ventilation therapy not only for acute respiratory distress syndrome patients but also for all types of acute respiratory insufficiency. This review presents the two main chapters of the guideline on choosing the mode of mechanical ventilation and setting its parameters. The guideline group aimed that - by thorough implementation of the recommendations - critical care teams may further improve the quality of care for patients suffering from acute respiratory insufficiency. By identifying relevant gaps of scientific evidence, the guideline group intended to support the development of important research projects.

7.
Geburtshilfe Frauenheilkd ; 79(8): 800-812, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31423016

RESUMO

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recent scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods Based on the international literature, the members of the participating medical societies and organizations developed Recommendations and Statements. These were adopted following a formal process (structured consensus conference with neutral moderation, voting was done in writing using the Delphi method to achieve consensus). Recommendations Part I of this short version of the guideline lists Statements and Recommendations on the epidemiology, etiology, prediction and primary and secondary prevention of preterm birth.

8.
Geburtshilfe Frauenheilkd ; 79(8): 813-833, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31423017

RESUMO

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

9.
Implement Sci ; 14(1): 71, 2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288828

RESUMO

BACKGROUND: Evidence-based clinical practice guidelines (CPGs) are relevant sources for generating quality indicators (QIs). The objective of this study was to compare guideline-based QIs of German and international CPGs and their underlying methodological approaches. METHODS: We conducted systematic searches in the guideline databases of G-I-N (Guidelines International Network) and NGC (National Guideline Clearinghouse) between February and June 2017 to identify international CPGs matching the topics of German evidence-based CPGs (n = 35) that report QIs, which were identified in a preceding study. Additionally, we searched the websites of the particular CPG providers for separate documents with regard to QIs. We included evidence-based CPGs which report QIs. Reported QIs, the underlying guideline recommendations, and information on methods of development were extracted. The selection and extraction of CPGs were conducted by one reviewer and checked by another. For each matched pair of CPGs, we assessed whether the suggested QIs matched or were not directly comparable. RESULTS: Twenty-five international CPGs, originating from seven CPG providers in total, met the criteria for inclusion. They matched the topics of 18 German CPGs. This resulted in 30 CPG pairs for the comparison of QIs (some of the international CPGs matched the topic of more than one German CPG). We found 27 QI pairs with QIs "not different or slightly different", corresponding to 13% (27 of 212) of the QIs in German CPGs and 16% (27 of 166) in international CPGs. Only two QI pairs were judged to be "different/inconsistent". For 183 of 212 (86%) QIs from German CPGs and 137 of 166 (83%) QIs from international CPGs, no direct comparison could be made. An explicit link to one or more guideline recommendations was found for 136 of 152 (89%) QIs from German CPGs and 82 of 166 (49%) QIs from international CPGs. Some information on methods for the development of QIs existed for 12 of 18 (67%) German CPGs and 8 of 25 (32%) international CPGs. CONCLUSIONS: The majority of QIs in German and international CPGs were not comparable. Various reasons for this are conceivable. More transparent reporting of the underlying methods for generating guideline-based QIs is needed.


Assuntos
Assistência à Saúde/normas , Guias de Prática Clínica como Assunto/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Bases de Dados Factuais , Alemanha , Humanos , Internacionalidade
10.
Dtsch Med Wochenschr ; 144(14): 990-996, 2019 07.
Artigo em Alemão | MEDLINE | ID: mdl-31096279

RESUMO

The AWMF and its medical societies perceive an increasing dominance of economic targets in the hospital health care sector, leading to impairment of patient care. While resource use in health care should be appropriate, efficient and fairly allocated, "economization" creates a burdensome situation for physicians, nurses and other health care professionals.The AMWF and the medical societies studied causes and developed measures for a scientific, patient-centred and resource-conscious medical care. Disincentives due to the remuneration system, number and equipment of hospitals resp. specialist departments and their basic funding need to be overcome. Proposed actions relate to the patient-doctor-level, the management level of hospitals and the level of planning and financing hospitals including compensation of hospital care. To place patients and their health in the forefront again, joint efforts of all stakeholders in health care are needed.


Assuntos
Economia Hospitalar , Administração Hospitalar , Assistência Centrada no Paciente/economia , Sociedades Médicas/organização & administração , Humanos
11.
Geburtshilfe Frauenheilkd ; 79(2): 148-159, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30792545

RESUMO

Aims Annual opportunistic screening for cervical carcinoma has been carried out in Germany since 1971. The creation of this S3 guideline meets an important need, outlined in the National Cancer Plan, with regard to screening for cervical cancer, as the guideline aims to provide important information and support for planned organized screening for cervical cancer in Germany. Methods With the financial support of German Cancer Aid, 21 professional societies developed evidence-based statements and recommendations (classified using the GRADE system) for the screening, management and treatment of precancerous conditions of the cervix. Two independent scientific institutes compiled systematic reviews for this guideline. Recommendations The first part of this short summary presents the pathological basis and considers various questions related to screening for cervical cancer. As also reported in earlier reviews, the meta-analysis by Kleijnen Systematic Reviews showed that HPV-based screening offers better protection against invasive cervical cancer compared to cytology-based screening. The authors of this guideline therefore recommend - in accordance with the guideline of the Joint National Committee of Germany (Gemeinsamer Bundesauschuss, G-BA) - that women aged 35 and above should be examined at regular intervals (at least every 3 years) and undergo HPV-based screening. Co-testing can also be carried out. Women between the ages of 20 and 35 should have cytological screening every 2 years.

12.
Geburtshilfe Frauenheilkd ; 79(2): 160-176, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30792546

RESUMO

Aims Annual opportunistic screening for cervical carcinoma has been done in Germany since 1971. The creation of this S3 guideline meets an important need, outlined in the National Cancer Plan, with regard to screening for cervical cancer, as this guideline aims to provide important information and support for planned organized screening for cervical cancer in Germany. Methods With the financial support of German Cancer Aid, 21 professional societies developed evidence-based statements and recommendations (classified using the GRADE system) for the screening, management and treatment of precancerous conditions of the cervix. Two independent scientific institutes compiled systematic reviews for this guideline. Recommendations The second part of this short summary deals with the triage, treatment and follow-up care of cervical dysplasia. With regard to those women who do not participate in screening, the guideline authors recommend sending out repeat invitation letters or an HPV self-collection kit. Colposcopy should be carried out for further investigation if cytology findings are Pap II-p and HPV test results are positive or if the results of an HPV 16 or HPV 18 screening test are positive. A single abnormal Pap smear should be triaged and investigated using HPV testing or p16/Ki67 dual staining.

13.
Geburtshilfe Frauenheilkd ; 78(11): 1056-1088, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30581198

RESUMO

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.

14.
Geburtshilfe Frauenheilkd ; 78(10): 927-948, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30369626

RESUMO

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Methods The process of updating the S3 guideline dating from 2012 was based on the adaptation of identified source guidelines which were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and the results of a systematic search of literature databases and the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point to develop recommendations and statements which were modified and graded in a structured consensus procedure. Recommendations Part 1 of this short version of the guideline presents recommendations for the screening, diagnosis and follow-up care of breast cancer. The importance of mammography for screening is confirmed in this updated version of the guideline and forms the basis for all screening. In addition to the conventional methods used to diagnose breast cancer, computed tomography (CT) is recommended for staging in women with a higher risk of recurrence. The follow-up concept includes suggested intervals between physical, ultrasound and mammography examinations, additional high-tech diagnostic procedures, and the determination of tumor markers for the evaluation of metastatic disease.

15.
Syst Rev ; 7(1): 5, 2018 01 12.
Artigo em Inglês | MEDLINE | ID: mdl-29329578

RESUMO

BACKGROUND: Quality indicators (QIs) are used in assessing the quality of healthcare. Evidence-based clinical practice guidelines (CPGs) are relevant sources for generating QIs. In this context, QIs are important tools to assess the implementation of guideline recommendations. However, the methodological approaches to guideline-based QI development vary considerably. In Germany, the guideline classification scheme of the AWMF (German Association of the Scientific Medical Societies) differentiates between S1-, S2k-, S2e-, and S3-CPGs depending on the methodological approach. Thus, S3-CPGs are consensus- and evidence-based CPGs and have the highest methodological standard in Germany. An analysis of the status quo of reported QIs in S3-CPGs found 35 current S3-CPGs, which report 372 different QIs. Currently, there is no gold standard for the development of guideline-based QIs. To our knowledge, no studies have investigated to what extent guideline-based QIs from different CPGs that are related to the same topic are consistent. The objective of this study is to compare guideline-based QIs and their underlying methodological approaches of German S3-CPGs with those of topic-related international CPGs. METHODS: Based on the previous identified German S3-CPGs (n = 35), which report quality indicators, we will conduct systematic searches in the guidelines databases of G-I-N (Guidelines International Network) and NGC (National Guideline Clearinghouse) to identify international CPGs matching the topics of the S3-CPGs. If necessary, we will search additionally the websites of the particular CPG providers for separate documents with regard to QIs. We will include evidence-based CPGs which report QIs. Reported QIs as well as methods of development and the rationale for QIs will be extracted and compared with those of the S3-CPGs. DISCUSSION: This study will be part of the project "Systematic analysis of the translation of guideline recommendations into quality indicators and development of an evidence- and consensus-based standard," supported by the German Research Association (DFG). The results of this analysis will feed into a subsequent qualitative study, which will consist of structured interviews with developers of international CPGs. Further, the results will be considered in a consensus study on standards of the translation of guideline recommendations into quality indicators in Germany.


Assuntos
Protocolos Clínicos/normas , Assistência à Saúde/normas , Guias como Assunto/normas , Internacionalidade , Indicadores de Qualidade em Assistência à Saúde/normas , Bases de Dados Factuais , Alemanha , Humanos
16.
Acta Obstet Gynecol Scand ; 97(5): 521-535, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29215155

RESUMO

INTRODUCTION: The number of clinical trials investigating the optimal timing of prophylactic antibiotics in cesarean section has increased rapidly over the last few years. We conducted a systematic review to inform up-to-date evidence-based guidelines to prevent postpartum infectious morbidity in the mother and rule out any safety issues related to antepartum antibiotic exposure in infants. MATERIAL AND METHODS: Four bibliographic databases were searched for published reports of trials. Ongoing or unpublished studies were searched in Clinicaltrials.gov and the World Health Organization registry platform. Randomized controlled trials comparing antibiotic prophylaxis before and after cord clamping in cesarean section were eligible. Maternal and neonatal outcomes were assessed, and certainty of evidence graded. RESULTS: In total, 18 randomized controlled trials met the inclusion criteria. Those women who received antibiotics preoperatively were 28% (relative risk 0.72, 95% confidence interval 0.56-0.92, nine studies, 4342 women, high quality of evidence) less likely to show infectious morbidity as compared with those who received antibiotics after cord clamping. The risk of endomyometritis and/or endometritis was reduced by 43% (relative risk 0.57, 95% confidence interval 0.40-0.82, 13 studies, 6250 women, high quality of evidence) and the risk of wound infection by 38% (relative risk 0.62, 95% confidence interval 0.47-0.81, 14 studies, 6450 women, high quality of evidence) in those who received antibiotics preoperatively as compared to those who received antibiotics after cord clamping. For other maternal infections no significant differences were identified. The risk for neonatal outcomes, such as deaths attributed to infection, sepsis, neonatal antibiotic treatment, intensive care unit admission or antibiotic-related adverse events, was not found to be different, either clinically or statistically, when antibiotics were given before or after cord clamping (moderate to low quality of evidence). CONCLUSIONS: The evidence in favor of prophylactic antibiotic administration before, in comparison with after, cord clamping for major maternal infections was of high quality, meaning that further research would be unlikely to change the confidence in these findings. However, we recommend additional research reflecting the precision of the effect estimates for neonatal outcomes.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Cesárea , Cuidados Pré-Operatórios/métodos , Infecção Puerperal/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Cordão Umbilical , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/efeitos adversos , Constrição , Esquema de Medicação , Feminino , Humanos , Assistência Perinatal/métodos , Gravidez , Cuidados Pré-Operatórios/efeitos adversos , Infecção Puerperal/etiologia
17.
Dtsch Arztebl Int ; 115(50): 840-847, 2018 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-30722839

RESUMO

BACKGROUND: Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care). METHODS: This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus. RESULTS: Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate). CONCLUSION: Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.


Assuntos
Oxigenação por Membrana Extracorpórea/instrumentação , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório do Adulto/terapia , Insuficiência Respiratória/diagnóstico , Doença Aguda , Deambulação Precoce/normas , Alemanha/epidemiologia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Metanálise como Assunto , Consumo de Oxigênio , Respiração com Pressão Positiva/instrumentação , Decúbito Ventral/fisiologia , Troca Gasosa Pulmonar/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Insuficiência Respiratória/sangue , Insuficiência Respiratória/fisiopatologia , Volume de Ventilação Pulmonar , Desmame do Respirador/métodos , Desmame do Respirador/normas
18.
BMC Pregnancy Childbirth ; 17(1): 399, 2017 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-29187156

RESUMO

BACKGROUND: Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental and clinical studies indicate that prolonged oxytocin exposure in the first or second stage of labour may be associated with impaired uterine contractility and an increased risk of atonic PPH. Therefore, particularly labouring women requiring cesarean delivery constitute a subset of patients that may exhibit an unpredictable response to oxytocin. We mapped the evidence for comparative studies investigating the hypothesis whether the risk for PPH is increased in women requiring cesarean section after induction or augmentation of labour. METHODS: We performed a systematic literature search for clinical trials in Medline, Embase, Web of Science, and the Cochrane Library (May 2016). Additionally we searched for ongoing or unpublished trials in clinicaltrials.gov and the WHO registry platform. We identified a total of 36 controlled trials investigating the exogenous use of oxytocin in cesarean section. Data were extracted for study key characteristics and the current literature literature was described narratively. RESULTS: Our evidence map shows that the majority of studies investigating the outcome PPH focused on prophylactic oxytocin use compared to other uterotonic agents in the third stage of labour. Only 2 dose-response studies investigated the required oxytocin dose to prevent uterine atony after cesarean delivery for labour arrest. These studies support the hypotheses that labouring women exposed to exogenous oxytocin require a higher oxytocin dose after delivery than non-labouring women to prevent uterine atony after cesarean section. However, the study findings are flawed by limitations of the study design as well as the outcome selection. No clinical trial was identified that directly compared exogenous oxytocin versus no oxytocin application before intrapartum cesarean delivery. CONCLUSION: Despite some evidence from dose-response studies that the use of oxytocin may increase the risk for PPH in intrapartum cesarean delivery, current research has not investigated the prepartal application of oxytocin in well controlled clinical trials. It was striking that most studies on exogenous oxytocin are focused on PPH prophylaxis in the third stage of labour without differing between the indications of cesarean section and hence the prepartal oxytocin status.


Assuntos
Cesárea/efeitos adversos , Ocitócicos/efeitos adversos , Ocitocina/efeitos adversos , Hemorragia Pós-Parto/induzido quimicamente , Inércia Uterina/tratamento farmacológico , Adulto , Feminino , Humanos , Trabalho de Parto Induzido , Mortalidade Materna , Ocitócicos/administração & dosagem , Ocitocina/administração & dosagem , Hemorragia Pós-Parto/mortalidade , Gravidez , Fatores de Risco , Prova de Trabalho de Parto , Adulto Jovem
20.
Z Evid Fortbild Qual Gesundhwes ; 129: 3-11, 2017 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-29157559

RESUMO

The question of how to improve healthcare quality and the need for patient empowerment and shared decision-making has been the subject of political and scientific debate for years. In addition to various quality initiatives, "top lists" summarizing selected recommendations to increase awareness of overuse, spread by means of public campaigns, has become popular on the international level - known as the "Choosing Wisely" initiative. However, the trustworthiness of "top lists", their impact on patient-relevant outcomes, their role in and integration into the context of the various pre-existing approaches to improve healthcare quality and the effects of neglecting under- and misuse are not clear. On the other hand, "top lists" may provide new opportunities to improve awareness and dissemination of carefully selected recommendations based on high-quality guidelines. Therefore, the Association of Scientific Medical Societies in Germany (AWMF) has established an ad hoc commission to design a system-specific initiative. The commission has the task to clarify goals, methods of development and concepts for implementation and evaluation, to address concerns and to build upon specific existing resources - e. g., the established quality management system for guidelines in Germany. The key goals defined by the commission include the systematization of the dialogue between healthcare practitioners and patients and the promotion of ethically founded decision-making as an answer to an increasing economic orientation of the healthcare system. To ensure the methodological quality of specific recommendations, the commission has developed a manual. To the best of our knowledge, this manual is the first detailed method paper aiming to guide developers of "Choosing Wisely" recommendations. More than 20 German medical scientific societies have already addressed the subject of "top lists".


Assuntos
Assistência à Saúde/normas , Qualidade da Assistência à Saúde , Tomada de Decisões , Alemanha , Humanos , Sociedades Médicas , Sociedades Científicas
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