Evidence-based clinical practice guidelines on some important aspects of the care of critically ill surgical patients Part II: Surgical intensive care units, implementation of guidelines

The first part of the critical care guidelines of the Philippine College of Surgeons (PCS) and supported by Glaxo Wellcome Philippines, Inc. dealt with resuscitation fluids, blood transfusion, assessment of volume resuscitation, nutritional support and cardiovascular support. The second part deals with the last 2 aspects identified by the Technical Working Group (TWG) namely: surgical intensive care units and implementation of guidelines. The literature search, limited to english publications. Used both electronic and manual methods. Three electronic databases were used: 1) The Cochrane Library, Issue 4, 2000; 2) National Library of Medicine - Medline (PubMed, no time limit): and HERDIN (Health Research and Development Information Network) Version 1, 1997 of DOST-PCHRD. Manual searching of the reference lists of review articles and some important meta-analyses and randomized controlled trials (RCTs) was also done. The search terms used were: 1) Cochrane library: surgical intensive care, guidelines implementation, 2) Medline: surgical intensive care, 3) HERDIN: intensive care. Titles of all articles were printed and all members of the TWG went over the list and checked the titles of articles whose abstracts they felt should be read. The abstracts of all checked articles were printed. The printed abstracts were given to the members, who then decided which articles were to be included for full text retrieval. The full texts were obtained from the University of the Philippines Manila Library, and were appraised using standard forms. (Author)

Evidence-based clinical practice guidelines on the diagnosis and management of breast cancer part I. Early breast cancer

The clinical area identified by the Philippine College of Surgeons (PCS) for the third evidence-based clinical practice guidelines (EBCPGs) was on the management of breast cancer. Funding for the research project was provided by the Philippine Council for Health Research and Development (PCHRD), and a Technical Working Group (TWG) was formed, composed of 5 general surgeons and 1 medical oncologist. The TWG was tasked to identify the clinical questions and to adhere to the PCS approved method of developing EBCPGs. The TWG decided to divide the report into two parts: Early Breast Cancer, and Locally Advanced and Metastatic Breast Cancer. This first report will focus on Early Breast Cancer The definition of early breast cancer is that used by the Early Breast Cancer Trialists Collaborative Group (EBCTG), since the regular systemic reviews (meta-analysis) of the group on the primary and adjuvant therapies of early breast cancer currently comprise the strongest evidence. "In women with "early breast cancer", all detectable cancer is, by definition, restricted to the breast and, in the case of node positive patients, the local lymph nodes can be removed surgically." The TWG began work on July 1, 2000. The literature search, limited to English publications, used both electronic and manual methods. Three electronic databases were used: 1) The Cochrane library, Issue 2, 2000; 2) National Library of Medicine-Medline (PubMed, no time limit); and HERDIN (Health Research and Development Information Network) Version 1, 1997 of DOST-PCHRD Titles of all articles were printed and at least 2 members of the TWG went over the list and checked the titles of articles whose abstract they felt should be read. The abstracts of all checked articles were printed. The printed abstracts were given to the members of the TWG, who then decided which articles were to be included for full text retrieval. The full texts were obtained from the University of the Philippines Manila Library, and were appraised using standard forms. The TWG then compiled, summarized and classified the evidence according to 3 levels and proposed a first draft to recommendations according to 3 categories.(Author)

Evidence-based clinical practice guidelines on seeking referral for preoperative cardiac evaluation for elective noncardiac surgery

The Philippine Council for Health Research and Development-Department of Science and Technology (PCHRD-DOST), and the Philippine College of Surgeons (PCS) signed a Memorandum of Agreement on 1 June 1999, whereby both agreed to support the formation of Evidence-Based Clinical Practice Guidelines (EBCPGs) on specific areas of surgical care in the Philippines. The areas were to be specified by the PCS, and those areas should have a reasonably large potential of improving the quality of patient care throughout the country, and can be implemented nationwide in both government and private health facilities The first clinical area selected was on when to refer for preoperative cardiac evaluation for elective noncardiac surgery, and when would the intraoperative presence of a cardiologist be beneficial. A Technical Working Group (TWG) was appointed, which: 1) searched and appraised the evidence; 2) prepared a first draft EBCPG; 3) presented the evidence to a Panel of Experts; 4) supervised the panel using the nominal group technique (6 November 1999 - PCS Building); and 5) prepared the second draft EBCPG based on the consensus recommendations of the panel. All processes strictly conformed to the methods of evidence-based guidelines formation specified by evidence-baesd medicine texts The second draft EBCPG was presented on 11 December 1999 during the 55th Clinical Congress of the PCS, and the final draft approved by the PCS Board of Regents on 29 January 2000 Literature search was conducted through the MEDLINE, COCHRANE Library an the HERDIN Database. A total of 2,156 titles, 427 abstracts and 77 full text articles were appraised. Data from 23 prospective cohort studies were encoded into the software COCHRANE Review Manager (RevMan), Version 3.0 for Windows (updated October 7, 1996). Tables were generated which contained authors, outcome rates, relative risks and the 95% confidence intervals of the relative risks. Three perioperative outcomes were identified-cardiac morbidity, cardiac death, and overall cardiac events

Stomach cancer incidence in Metro Manila and Rizal province: 1980-1992

Incidence was derived from published data from 2 population-based registries - the Philippine Cancer Society - Manila Cancer Registry and the Department of Health-Rizal Cancer Registry, which covered 8.5 million residents (1990 census) of a 1,674 square kilometer area that comprises Metro Manila and Rizal province. Thirteen registry clerks actively sought new cancer cases in 96 hospitals and 30 Civil Registry offices. Both registries are members of the International Association of Cancer Registries and received continuing professional assistance from the International Agency for Research on Cancer (IARC). For the period 1988-1992 the combined age-standardized incidence rate (ASR) was 9.9 per 100,000 for male stomach cancer (ranked fifth, 4.5% of all male cancers), and 5.9 per 100,000 among females (ranked ninth, 2.8% of all female cancers). Stomach cancer among Philippine residents had lower ASRs and age-specific rates compared to Japanese, Korean, Chinese, Singaporean Chinese and Vietnamese populations. Age-specific rates among Filipinos reached 10 per 100,000 or higher at age-group 50-54 years among males, and 55-59 years among females. Significant differences in incidence were observed in only few cities and municipalities. There were little differences in ASRs between 2 populations during 3 time periods between 1980-1992, in both males and females with an indication of a slight decrease. Incidence of male Philippine migrants to Hawaii, San Francisco and Los Angeles were comparable to those of white residents covered by the Manila registry. Among females, stomach cancer incidence of Philippine residents and Filipina migrants to Hawaii were similar, and were slightly higher than those of white residents in Hawaii and both migrants and white residents in San Francisco and Los Angeles

Pancreas cancer incidence in Metro Manila and Rizal province: 1980-1992

Incidence was derived from published data from 2 population-based registries-the Philippine Cancer Society-Manila Cancer Registry and the Department of Health-Rizal Cancer Registry, which covered 8.5 million residents (1990 census) of a 1,674 square kilometer area that comprises Metro Manila and Rizal province. Thirteen registry clerks actively sought new cancer cases in 96 hospitals and 30 Civil Registry offices. Both registries are members of the International Association of Cancer Registries and receive continuing professional assistance from the International Agency for Research on Cancer (IARC). For the period 1988-1992 the combined age-standardized incidence rates (ASR) of pancreas cancer in males was 4.2 per 100,000 (ranked eleventh) and 3.2 per 100,000 in females (ranked fourteenth). Pancreas cancer rates for both sexes were lower than those observed among North America and European populations. Within region, Philippine rates were lower than Japanese, Korean, Chinese and Singaporean Chinese, but were higher than Vietnamese and Thai populations. Among males, the increase in age-specific rates were highest among those 55 years and older, and at age-group 65 years and older among females. There were significant differences in rates between some cities and municipalities, with the rates in some highly urbanized cities two to three times those seen in rural areas. Average annual rates among males and females had hardly changed in the 13-year period between 1980-1992 but total cases had tripled. ASRs of Filipino male migrants of the U.S.A were similar to that observed among Filipinos residing in the Philippines. Female migrants to San Francisco and Los Angeles had higher rates than Philippine residents

Prostate cancer incidence in Metro Manila and Rizal province: 1980-1992

Incidence was derived from published data from 2 population-based registries-the Philippine Cancer Society-Manila Cancer registry and the Department of Health-Rizal Cancer Registry, which covered 8.5 million residents (1990 census) of a 1,674 square kilometer area that comprises Metro Manila and Rizal province. Thirteen registry clerks actively sought new cancer cases in 96 hospitals and 30 Civil Registry offices. Both registries are members of the International Association of Cancer Registries and receive continuing professional assistance from the International Agency for Research on Cancer (IARC). For the period of 1988-1992 the combined age-standardized incidence rate (ASR) was 17.0, prostate cancer ranked third and comprised 6.1 per cent of all male cancers. Prostate cancer rates were lower than those observed among North American and European populations, but within the Asian region, Philippine rates were higher than most Asian populations. Age-specific rates increased considerably at age-group 66-59 years and continued to increase with increasing age. There were significant differences in rates between cities and municipalities, with the rates in some highly urbanized cities double those seen in urbanizing areas, and triple those seen in rural areas. Rates had increased slightly in the 13-year period between 1980-1992 but total cases had triples. Incidence rates among Filipino migrants to Hawaii, San Francisco and Los Angeles were almost 3 times higher than rates seen in Philippines residents, but were still only half of those seen among the white populations.

Nasopharynx cancer incidence in Metro Manila and Rizal provinces: 1980-1992

Incidence was derived from published data from 2 population-based registries-the Philippine Cancer Society-Manila Cancer Registry and Department of Health-Rizal Cancer Registry, which covered 8.5 million residents (1990 census) of a 1,674 square kilometer area that comprises Metro Manila and Rizal province. Thirteen registry clerks actively sought new cancer cases in 96 hospitals and 30 Covil Registry offices. Both registries are members of the International Association of Cancer Registries and receive continuing professional assistance from the International Agency for Research on Cancer (IARC). For the period of 1988-1992 the combined age-standardized incidence rates (ASR) were: 6.8 for male nasopharynx cancer (NPC) (ranked sixth) and 3.2 among females (ranked thirteenth). NPC for both sexes were highest among Asian populations. Within the region, Philippine rates were third highest, following the Singapore Chinese and Vietnamese. Age-specific rates in males reached 10 per 100,000 at age-group 40-49 years, and 5 per 100,000 females at age-group 45-49 years, continuing to rise with increasing age. There were some significant differences in ASRs between some cities and municipalities but the differences were more striking among males as female rates were lower. Rates had increased only very slightly in the 13-year period between 1980-1992 but total cases had triples. NPC ASRs among male Filipino migrants to the USA were only half of that observed in Philippine residents, but were still higher than the rates among White residents. A similar decrease was seen among female migrants, and in Los Angeles the rates of Filipinos and non-Hispanic White females were already similar

Liver cancer incidence in Metro Manila and Rizal province: 1980-1992

Incidence was derived from published data from 2 population-based registries-the Philippine Cancer Society-Manila Cancer Registry and the Department of Health-Rizal Cancer Registry, which covered 8.5 million residents (1990 census) of a 1,674 square kilometer area that comprises Metro Manila and Rizal province. Thirteen registry clerks actively sought new cancer cases in 96 hospitals and 30 Civil Registry offices. Both registries are members of the International Association of Cancer Registries and receive continuing professional assistance from the International Agency for Research on Cancer (IARC). For the period 1988-1992 the combined age-standardized incidence rates (ASR) were 21.2 for male liver cancer (ranked second), and 7.3 in females (ranked seventh). Liver cancer rates for both sexes were higher than those observed among North American and European populations. Within the region, high rates were observed in both males and females in Thailand, Japan, China, Korea, Philippines, Singapore and Viet Nam. The rate begins to rise steeply at age-group 40-44 years among males and females. There were significant differences in rates between some cities and municipalities, with the rates in some areas double those seen in low incidence areas. Rates observed among Filipino migrants to the USA had decreased by around half of those seen among Philippine residents

The center for disease control-national nosocomial infection surveillance (CDC-NNIS) surgical patient risk index score and surgical site infections at UERMMMC

The study retrospectively reviewed 1,029 general surgery operations performed from September 1, 1991 to May 31, 1993 to find out the association between the occurrence of surgical site infection (SSI) and the Centers for Disease Control-National Nosocomial Infection Surveillance (CDC-AWS) surgical patient risk index scores. The index assigned 1 point for each of 3 risk factors: 1) American Society of Anesthesiologists (ASA) preoperative assessment class 3, 4 or 5; 2) an operational classified as either contaminated or dirty-infected; 3) an operation with a duration longer than a specified increased with increasing contamination (p=0.000) as well as increasing index scores (p=0.000). Looking at operations within the same category of contamination, SSI rates also increased with increasing scores among clean operations (p=0.944), clean-contaminated operations (p=0.000), contaminated operations (p=0.559), and dirty operations. SSI rates in this hospital series were compared to the 44-hospital CDC-NNIS report.

A multicenter randomized clinical trial comparing the clinical efficacy of Imipenem/Cilastin and Ceftazidime plus Metronidazole in surgically treated serious intra-abdominal infections

An open, prostective, randomized multicenter clinical trial randomly allocated successive patient who were scheduled for a surgical procedure for serious intra-abdominal infections to receive either treatment CM (ceftazidine plus metronidazole) or monotherapy with treatment IC (imipenem/cilastatin). Out of 90 eligible patients, 87 were clinically evaluable of which 71 were clinically and bacteriologically evaluable (CBE). Cases allocated to each treatment group were comparable as to age, sex, diagnostic group distribution, mean APACHE II scores, and bacteriologic evaluability. Among the 87 clinically evaluable patients, there were 4 (9.1%) and 2 (4.7%) treatment failures among those who received treatments CM and IC respectively (p=0.486). For all eligible patients, the mean fever days was 2.07, mean treatment days was 6.01, and mean hospital days was 11.57, and was not significantly different between the two treatment groups. Among clinically evaluable cases, the mean APACHE II scores of patients with succesful outcomes (5.8) was very significantly lower (p=0.000) than that of patients whose treatment failed (13.8). This was also true for CBE cases. Logistic regression analysis showed that among six variables (diagnostic group, APACHE II score, antibiotic used, fever days, hospital days and treatment days) only the APACHE II score signficantly contributed to treatment failure (p=0.001).