Best practice & research. Clinical rheumatology
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Best Pract Res Clin Rheumatol · Apr 2010
Challenges in using evidence to inform your clinical practice in low back pain.
The aim of evidence-based medicine (EBM) from its early days was to provide the appropriate means for making effective clinical decisions, not only for avoiding habitual practice but also for enhancing clinical performance. It is, however, unrealistic to simply assume that the results of research will soon evolve into practice. In this article, when aiming to translate results from research into practice, we focus on certain challenges, which can be broadly categorised into two: how the evidence is generated, and how the evidence is implemented. ⋯ Although the importance of implementing clinical guidelines is widely recognised, little is known about the optimal implementation strategy. We present two examples of implementing low back pain guidelines, illustrating that it remains difficult to develop effective implementation strategies. Finally, we discuss some future directions that have been proposed for EBM, which aim to overcome the essential tension between internal validity and external validity (generalisability), specifically in fields where complex syndromes and complex interventions are the focus of attention.
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Best Pract Res Clin Rheumatol · Feb 2010
ReviewDeveloping a minimum standard of care for treating people with osteoarthritis of the hip and knee.
We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of interventions, that should be offered to all patients with OA of the hip and/or knee. Eight core recommendations emerged where it is recommended that health-care professionals: Provide advice about, and offer access to appropriate information for OA self-management and lifestyle change; Provide advice about weight loss if patient is overweight or obese and refer to services as required; Provide advice for land-based exercises incorporating aerobic and strengthening components and refer to services as required; Recommend adequate paracetamol for pain relief; Make patients aware that non-steroid anti-inflammatory drugs (NSAIDs) or coxibs can improve symptoms in majority but this comes with potential for harm and that risk potential varies--be aware of and minimise the individual's risk potential; Offer intra-articular steroids for short-term relief of a flare or acute deterioration in symptoms; Offer stronger analgesic relief if prolonged severe symptoms; Offer access to assessment for arthroplasty for consumers with severe symptomatic OA not responding to conservative therapy. An integrated, chronic disease model of care is proposed to best implement OA management and a check list of clinical indicators/performance measures is provided.
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Best Pract Res Clin Rheumatol · Aug 2009
ReviewRespiratory manifestations of systemic lupus erythematosus: old and new concepts.
The respiratory system is commonly involved in systemic lupus erythematosus. Lung disorders are classified as primary (due to lupus) and secondary to other conditions. Pleuritis and pulmonary infections are the most prevalent respiratory manifestations of each type. ⋯ Larger controlled trials of the different therapies in the treatment of those lung manifestations of lupus are needed. Overall malignancy is little increased in lupus, but lung cancer and non-Hodgkin's lymphoma are among the most frequent types of cancer found in these patients. As survival in lupus patients has improved over recent decades, avoiding pulmonary damage emerges as an important objective.
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Churg-Strauss angiitis or syndrome (CSA) is defined as an eosinophil-rich and granulomatous inflammation involving the respiratory tract, and necrotising vasculitis affecting small- to medium-sized vessels, and is associated with asthma and eosinophilia. It is usually classified among the so-called anti-neutrophil antibody (ANCA)-associated systemic vasculitides (AASVs) because of its clinical and pathological features that overlap with those of the other AASVs. However, two recent studies on large cohorts of patients have found that ANCAs, usually P-ANCAs/MPO-ANCAs, were present in only 38% of patients. ⋯ The addition of cyclophosphamide is indicated in treatment of patients with poor-prognosis factors or in patients without poor-prognosis factors but those that are prone to relapses. The length of the maintenance therapy remains to be established. However, the vast majority of patients require long-term corticosteroids treatment to control asthma.
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Among the most important reasons for the increased use of ultrasound by rheumatologists is its feasibility to guide injections. Correct positioning of the needle in the targeted structure occurs much more frequently with ultrasound guidance than with conventional positioning without imaging. The sonographer can mark the skin above the structure, using ultrasound to localize this point and to estimate the depth of the structure. ⋯ Education involves training to coordinate probe and needle in sponges, chicken, cheese and other objects. Knowledge of anatomy, probe positioning and the ability to coordinate probe and needle are necessary when injecting patients with sonographic guidance. The rheumatologist might start with easy approaches in which the needle is parallel to the probe.