RATIONALE: In 2008, the Philippine College of Surgeons in collaboration with the Philippine Society of General Surgeons and the Philippine Academy of Head and Neck Surgeons, Inc. had published Evidence-based Clinical Practice Guidelines (CPG) on the Diagnosis and Management of Thyroid Nodules. This was followed by an update in 2013 with a focus on important diagnostic and therapeutic management issues concerning thyroid malignancy. The objective of this study was to assess knowledge gaps and behavioral patterns among users with respect to these CPGs. METHODS: A validated 30 item survey assessing knowledge of, attitudes towards, and adherence to the recommendations of different Evidence based Clinical Practice Guidelines was administered to general surgery residents, PSGS fellows, and otorhinolaryngology residents and consultants performing thyroidectomies. RESULTS: There were 343 assessable forms. Of the respondents, 276 (80.47%) were general surgeons, 33 (9.62%) were otorhinolaryngologists. There were 66 (19.24%) consultants, and 277 (80.76%) residents. Otorhinolaryngologists were less aware of the local CPGs than their GS counterparts. GS Residents, compared to their consultants, were more aware of the American Thyroid Association guidelines than the local guidelines. Among all respondents, the local guidelines had about equal preference for usage as the American Thyroid Association guidelines. There were no statistically significant differences on the level of knowledge and attitudes among the respondents. CONCLUSION The level of awareness about the PCS Thyroid Guidelines needs to be improved. The dissemination process needs to be reviewed and ensure that all stakeholders will be reached.
thyroids ; clinical practice guidelines

Adult ; Betacoronavirus ; Clinical Laboratory Techniques ; Coronavirus Infections ; diagnosis ; epidemiology ; etiology ; prevention & control ; therapy ; Diagnosis, Differential ; Extracorporeal Membrane Oxygenation ; Humans ; Pandemics ; prevention & control ; Pneumonia, Viral ; epidemiology ; etiology ; prevention & control ; therapy ; Practice Guidelines as Topic ; Respiration, Artificial

Real world study (RWS) has attracted more and more attention of neonatologists since it involves less clinical intervention and is closer to actual clinical conditions. Generally speaking, RWS means to select treatment measures based on the internal efficacy and safety verified by randomized controlled trials (RCTs), more representative samples, and patients' actual conditions and their guardians' will and conduct follow-up evaluation of short- and long-term outcomes, in order to further evaluate the external efficacy and safety of interventional measures. Most guidelines for clinical practice are based on RCTs and lack the support of real world data. Strengthening of neonatal RWS helps to make these guidelines more practical and thus promotes the development of neonatal medicine.
Humans ; Infant, Newborn ; Neonatology ; Noninvasive Ventilation ; Practice Guidelines as Topic ; Pragmatic Clinical Trials as Topic ; Randomized Controlled Trials as Topic ; methods

Clinical practice guidelines (CPGs) have become ubiquitous in every field of medicine today but there has been limited success in implementation and improvement in health outcomes. Guidelines are largely based on the results of traditional randomised controlled trials (RCTs) which adopt a highly selective process to maximise the intervention's chance of demonstrating efficacy thus having high internal validity but lacking external validity. Therefore, guidelines based on these RCTs often suffer from a gap between trial efficacy and real world effectiveness and is one of the common reasons contributing to poor guideline adherence by physicians. "Real World Evidence" (RWE) can complement RCTs in CPG development. RWE-in the form of data from integrated electronic health records-represents the vast and varied collective experience of frontline doctors and patients. RWE has the potential to fill the gap in current guidelines by balancing information about whether a test or treatment works (efficacy) with data on how it works in real world practice (effectiveness). RWE can also advance the agenda of precision medicine in everyday practice by engaging frontline stakeholders in pragmatic biomarker studies. This will enable guideline developers to more precisely determine not only whether a clinical test or treatment is recommended, but for whom and when. Singapore is well positioned to ride the big data and RWE wave as we have the advantages of high digital interconnectivity, an integrated National Electronic Health Record (NEHR), and governmental support in the form of the Smart Nation initiative.
Big Data ; Electronic Health Records ; Evidence-Based Medicine ; Guideline Adherence ; Humans ; Practice Guidelines as Topic ; Practice Patterns, Physicians' ; Pragmatic Clinical Trials as Topic ; Precision Medicine ; Singapore

PURPOSE: Postoperative nausea and vomiting (PONV) is very common among postoperative orthopedic surgical patients with patient-controlled analgesia (PCA), especially for narcotics. Therefore, the purpose of this study was to investigate the effects of an evidence-based PONV management protocol on nursing and patient outcomes. METHODS: A methodological study was conducted to develop PONV protocol and a quasi-experimental study to evaluate the effectiveness of protocol. The preliminary PONV protocol was drawn by conducting a systematic review and by reviewing clinical guidelines and best practice recommendations. Validation of the content was done by expert clinicians, and the clinical applicability was evaluated by staff nurses and patients. The effect was evaluated in clinical outcomes associated with PONV and nursing outcomes. RESULTS: In the experimental group, the occurrence of vomiting (z=2.147) was significantly decreased, the maintenance PCA (χ²=4.212) and the satisfaction of patients (z=5.007) were significantly higher. In the outcomes of nurses, the PONV knowledge of nursing care (z=3.791), awareness (z=2.982) and self-efficacy (z=2.745) were higher in the experimental group. The attitude towards evidence-based nursing practice (z=2.446) was significantly positive. CONCLUSION: The results show that an evidence-based approach to the implementation of PONV care is effective in improving patient clinical outcomes and quality of care.
Analgesia, Patient-Controlled ; Clinical Protocols ; Evidence-Based Nursing* ; Humans ; Methods ; Narcotics ; Non-Randomized Controlled Trials as Topic ; Nursing ; Nursing Care ; Orthopedics ; Passive Cutaneous Anaphylaxis ; Postoperative Nausea and Vomiting* ; Practice Guidelines as Topic ; Program Development ; Program Evaluation ; Vomiting

The NCCN has recently released its 2017 version 1.0 guideline for colorectal cancer. There are several updates from this new version guideline which are believed to change the current clinical practice. Update one, low-dose aspirin is recommended for patients with colorectal cancer after colectomy for secondary chemoprevention. Update two, biological agents are removed from the neoadjuvant treatment regimen for resectable metastatic colorectal cancer (mCRC). This update is based on lack of evidence to support benefits of biological agents including bevacizumab and cetuximab in the neoadjuvant setting. Both technical criteria and prognostic information should be considered for decision-making. Currently biological agents may not be excluded from the neoadjuvant setting for patients with resectable but poor prognostic disease. Update three, panitumumab and cetuximab combination therapy is only recommended for left-sided tumors in the first line therapy. The location of the primary tumor can be both prognostic and predictive in response to EGFR inhibitors in metastatic colorectal cancer. Cetuximab and panitumumab confer little benefit to patients with metastatic colorectal cancer in the primary tumor originated on the right side. On the other hand, EGFR inhibitors provide significant benefit compared with bevacizumab-containing therapy or chemotherapy alone for patients with left primary tumor. Update four, PD-1 immune checkpoint inhibitors including pembrolizumab or nivolumab are recommended as treatment options in patients with metastatic deficient mismatch repair (dMMR) colorectal cancer in second- or third-line therapy. dMMR tumors contain thousands of mutations, which can encode mutant proteins with the potential to be recognized and targeted by the immune system. It has therefore been hypothesized that dMMR tumors may be sensitive to PD-1 inhibitors.
Antibodies, Monoclonal ; pharmacology ; therapeutic use ; Antibodies, Monoclonal, Humanized ; therapeutic use ; Antineoplastic Agents ; therapeutic use ; Antineoplastic Combined Chemotherapy Protocols ; therapeutic use ; Aspirin ; administration & dosage ; therapeutic use ; Bevacizumab ; therapeutic use ; Biological Products ; therapeutic use ; Brain Neoplasms ; drug therapy ; genetics ; Cetuximab ; therapeutic use ; Clinical Decision-Making ; methods ; Colorectal Neoplasms ; drug therapy ; genetics ; pathology ; prevention & control ; therapy ; Contraindications ; Humans ; Mutation ; physiology ; Neoadjuvant Therapy ; standards ; Neoplasm Metastasis ; drug therapy ; Neoplastic Syndromes, Hereditary ; drug therapy ; genetics ; Practice Guidelines as Topic ; Prognosis ; Secondary Prevention ; methods ; standards

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.
Adult ; Cardiovascular Diseases ; complications ; therapy ; Child ; Coronary Artery Disease ; complications ; therapy ; Decision Support Systems, Clinical ; Dyslipidemias ; blood ; complications ; therapy ; Evidence-Based Medicine ; Female ; Humans ; Kidney Failure, Chronic ; complications ; therapy ; Life Style ; Lipids ; blood ; Lipoproteins, LDL ; blood ; Male ; Practice Guidelines as Topic ; Pregnancy ; Pregnancy Complications ; Risk Assessment ; Risk Factors ; Singapore

BACKGROUND: Sharps injury is a penetrating stab wound from a needle, scalpel, or another sharp object that may result in exposure to blood or other body fluids. According to World Health Organization pooled estimate, the annual incidence of sharps injury in Africa was ranged from 2.10 to 4.68 per person per year, but research data in Ethiopia is limited. The aim of the study was to investigate sharps injury prevalence and associated risk factors. METHODS: Institution based cross-sectional study was conducted with 200 healthcare providers (HCP) in Northeast Ethiopia. Proportionate stratified sampling was used to select HCP. Sharps injury during the last 12 months was an outcome variable whereas demographic characteristics, behavioral attributes, and job environment characteristics were independent variables. Data was collected from April to May 2016 using self-administered questionnaire; which was adapted from World Health Organization best practices for injections and related procedures toolkit. Bivariate and multivariate logistic regression analysis was carried out to identify sharps injury associated risk factors. Epi Info version 3.5.1 software package was used for data coding and entry whereas Statistical Package for Social Sciences (SPSS) version 20 software package was used for analysis. RESULTS: In total, 195 HCP participated with a response rate of 97.5%. The prevalence of sharps injury was 32.8%. Following adjustment for covariates, lack of in-service job training and previous exposure to sharps injury were statistically significant risk factors for sharps injury. HCP who had no in-service job training were 4.7 times more likely sustained sharps injury compared with those who had in-service job training (p < 0.001, OR = 4.7, 95% CI = 2.05–10.56). HCP who had previous exposure to sharps injury were 3.7 times more likely sustained sharps injury compared with those who were not exposed (p-value = 0.002, OR = 3.7, 95% CI = 1.62–8.27). CONCLUSIONS: This study revealed 32.8% or at least three out of ten HCP exposed to sharps injury. This was found statistically significant among HCP who had no in-service job training and who had previous exposure to sharps injury. Thus, training HCP perhaps increase their skill and curiosity to reduce exposure to sharps injury.
Africa ; Body Fluids ; Clinical Coding ; Cross-Sectional Studies ; Delivery of Health Care* ; Ethiopia* ; Health Personnel* ; Humans ; Incidence ; Logistic Models ; Needles ; Needlestick Injuries* ; Occupational Exposure* ; Practice Guidelines as Topic ; Prevalence ; Risk Factors ; Social Sciences ; World Health Organization ; Wounds, Stab

Clinical trials have established the benefits of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) in the treatment of heart failure patients. As adjuncts to guideline-directed medical therapy, ICDs confer mortality benefits from sudden cardiac arrest, while CRT reduces mortality, hospitalisation rates and improves functional capacity. This review discusses the use of ICDs and CRT devices in heart failure management, outlining the evidence supporting their use, indications and contraindications.
Asian Continental Ancestry Group ; Cardiac Resynchronization Therapy ; Cardiology ; Clinical Trials as Topic ; Death, Sudden, Cardiac ; Defibrillators, Implantable ; Heart Failure ; diagnostic imaging ; epidemiology ; therapy ; Humans ; Practice Guidelines as Topic ; Singapore ; Ventricular Dysfunction, Left ; therapy

BACKGROUND: Deficiencies in anaphylaxis management in Emergency Departments is well recognised despite established guidelines for its treatment. OBJECTIVE: To identify deficiencies in the management of anaphylaxis in a busy metropolitan Emergency Department and determine if an education intervention could correct these. METHODS: Paediatric and adult admissions to the Emergency Department of a busy hospital were tracked over a 10-month period with a targeted educational program being instituted at 5 months. The electronic records were retrospectively reviewed looking for cases of anaphylaxis and milder forms of immediate type allergic reactions presenting with a combination of urticaria and nonairway threatening angioedema. Anaphylaxis presentation was graded using the Brown grading system. Use of all medication during resuscitation was documented. Observation period before discharge and referral to specialist unit for follow-up was noted. RESULTS: In the first 5 months, 38 patients fulfilled our criteria. Three had severe anaphylaxis, 13 had moderately severe anaphylaxis and 12 had urticaria and angioedema without anaphylaxis. Anaphylaxis was not always recognised or graded leading to inappropriate management with adrenaline often being withheld. Promethazine, usually given in parenteral form, was frequently administered. Observation time was often inadequate. Referral to an immunologist was not universally followed through. Following the educational intervention 58 patients fulfilled our criteria over the next 5 months. The appropriate use of adrenaline increased by 21% and the use of sedating antihistamines decreased by 16%, while the number of referrals to an immunologist increased by 24%. There was an 11% reduction in the number of patients who were observed for at least 4 hours. CONCLUSION: A number of deficiencies in the management of anaphylaxis presentations have been identified. Targeted educational activities aimed at the Emergency Department hospital staff may improve outcomes.
Adult ; Anaphylaxis ; Angioedema ; Clinical Audit ; Education ; Emergencies ; Emergency Service, Hospital ; Epinephrine ; Follow-Up Studies ; Histamine H1 Antagonists ; Humans ; Hypersensitivity ; Practice Guidelines as Topic ; Promethazine ; Referral and Consultation ; Resuscitation ; Retrospective Studies ; Specialization ; Urticaria