Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature.

CONTEXT: Practice guidelines play an important role in medicine. Methodological principles have been formulated to guide their development. OBJECTIVE: To determine whether practice guidelines in peer-reviewed medical literature adhered to established methodological standards for practice guidelines. DESIGN: Structured review of guidelines published from 1985 through June 1997 identified by a MEDLINE search. MAIN OUTCOME MEASURES: Mean number of standards met based on a 25-item instrument and frequency of adherence. RESULTS: We evaluated 279 guidelines, published from 1985 through June 1997, produced by 69 different developers. Mean overall adherence to standards by each guideline was 43.1% (10.77/25). Mean (SD) adherence to methodological standards on guideline development and format was 51.1% (25.3%); on identification and summary of evidence, 33.6% (29.9%); and on the formulation of recommendations, 46% (45%). Mean adherence to standards by each guideline improved from 36.9% (9.2/25) in 1985 to 50.4% (12.6/25) in 1997 (P<.001). However, there was little improvement over time in adherence to standards on identification and summary of evidence from 34.6% prior to 1990 to 36.1 % after 1995 (P = .11). There was no difference in the mean number of standards satisfied by guidelines produced by subspecialty medical societies, general medical societies, or government agencies (P = .55). Guideline length was positively correlated with adherence to methodological standards (P = .001). CONCLUSION: Guidelines published in the peer-reviewed medical literature during the past decade do not adhere well to established methodological standards. While all areas of guideline development need improvement, greatest improvement is needed in the identification, evaluation, and synthesis of the scientific evidence.

Impact of age on the severity, course, and complications of alcohol withdrawal.

BACKGROUND: Early identification of alcohol-dependent patients at increased risk for severe or complicated alcohol withdrawal would improve triage and treatment. However, the role of age in predicting alcohol withdrawal outcomes has not been well studied. OBJECTIVE: To assess the impact of age on the severity, course, and complications of alcohol withdrawal. METHODS: We performed a retrospective cohort study of 284 inpatients admitted for alcohol withdrawal between September 1992 and August 1994. Outcomes included alcohol withdrawal severity measured by the revised Clinical Institute Withdrawal Assessment for Alcohol scale, quantity and duration of benzodiazepine therapy, and complications during withdrawal. RESULTS: Initial and maximal withdrawal severity scores, amount of benzodiazepine administered, and duration of benzodiazepine treatment for elevated withdrawal severity scores did not change significantly with age. However, patients aged 60 years and older had increased risk for delirium (adjusted odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-15.0; P = .008), falls (OR, 3.1; 95% CI, 0.9-11.2; P = .08), and transient dependency in 2 or more activities of daily living (OR, 5.8; 95% CI, 2.9-11.7; P < .001). As age increased, there were significant increases in length of stay (P < .001) and frequency of discharge to an extended care facility (P < .001). CONCLUSIONS: Although alcohol withdrawal severity scores and benzodiazepine requirements were similar across age groups, patients aged 60 years and older were at increased risk for cognitive and functional impairment during withdrawal. These findings support recommendations that older patients with alcohol withdrawal are best treated in closely supervised settings.

Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal.

OBJECTIVE: To provide an evidence-based practice guideline on the pharmacological management of alcohol withdrawal. DATA SOURCES: English-language articles published before July 1, 1995, identified through MEDLINE search on "substance withdrawal--ethyl alcohol" and review of references from identified articles. STUDY SELECTION: Articles with original data on human subjects. DATA ABSTRACTION: Structured review to determine study design, sample size, interventions used, and outcomes of withdrawal severity, delirium, seizures, completion of withdrawal, entry into rehabilitation, adverse effects, and costs. Data from prospective controlled trials with methodologically sound end points corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were abstracted by 2 independent reviewers and underwent meta-analysis. DATA SYNTHESIS: Benzodiazepines reduce withdrawal severity, reduce incidence of delirium (-4.9 cases per 100 patients; 95% confidence interval, -9.0 to -0.7; P=.04), and reduce seizures (-7.7 seizures per 100 patients; 95% confidence interval, -12.0 to -3.5; P=.003). Individualizing therapy with withdrawal scales results in administration of significantly less medication and shorter treatment (P<.001). beta-Blockers, clonidine, and carbamazepine ameliorate withdrawal severity, but evidence is inadequate to determine their effect on delirium and seizures. Phenothiazines ameliorate withdrawal but are less effective than benzodiazepines in reducing delirium (P=.002) or seizures (P<.001). CONCLUSIONS: Benzodiazepines are suitable agents for alcohol withdrawal, with choice among different agents guided by duration of action, rapidity of onset, and cost. Dosage should be individualized, based on withdrawal severity measured by withdrawal scales, comorbid illness, and history of withdrawal seizures. beta-Blockers, clonidine, carbamazepine, and neuroleptics may be used as adjunctive therapy but are not recommended as monotherapy.

Thermal epiglottitis in adults: a new complication of illicit drug use.

Four cases of acute epiglottitis due to thermal injury were identified in a larger study of 407 cases of epiglottitis in Rhode Island from 1975 through 1992. All occurred in young adults (aged 22-33 yr) and were caused by the inhalation of heated objects when smoking illicit drugs (a tip of a marijuana cigarette in 1 case and metal pieces from crack cocaine pipes in 3 cases). Symptoms, signs, and X-ray and laryngoscopic findings were similar to infectious epiglottitis. All recovered with observation and intravenous antibiotics; none required intubation. Emergency physicians should be aware of this etiology when managing young adults who present with acute epiglottitis.

Differences in generalists' and cardiologists' perceptions of cardiovascular risk and the outcomes of preventive therapy in cardiovascular disease.

OBJECTIVE: To compare generalists' and cardiologists' estimates of baseline cardiovascular risk and the outcomes of preventive therapy. DESIGN: Cross-sectional mail survey using written case simulations of typical patients from primary prevention trials for hypercholesterolemia and isolated systolic hypertension, and tertiary prevention studies of coronary artery bypass surgery for chronic stable angina with left main coronary stenosis. PARTICIPANTS: Nationally representative sample of 599 practicing family physicians, general internists, and cardiologists selected from the American Medical Association masterfile. Among eligible physicians, 84 (44%) of 191 family physicians, 77 (40%) of 194 general internists, and 66 (34%) of 194 cardiologists responded. MEASUREMENTS: Estimates of risk at baseline and after therapy, and whether therapy generally would be recommended. RESULTS: For both primary prevention case simulations (scenarios), cardiologists provided lower, more accurate estimates of baseline cardiovascular risk and of absolute therapeutic benefit than either family physicians or general internists. The range of the generalists' estimates was extremely wide. Perceptions of relative risk reduction and treatment recommendations for the primary prevention scenarios did not differ among specialties. Overall, generalists who would not recommend primary preventive therapy in these scenarios appeared to give more accurate estimates than did generalists who would recommend such therapy. CONCLUSIONS: Many generalists have inflated perceptions of cardiovascular risk without treatment and of the benefit of risk-modifying medical treatment. Further study should assess the reasons for these misperceptions and their effect on counseling about primary preventive therapy.

Acute epiglottitis. An 18-year experience in Rhode Island.

OBJECTIVE: To assess the incidence, clinical characteristics, management, and outcome of epiglottitis in a defined population over an 18-year period. DESIGN: Case series. SETTING: The state of Rhode Island, 1975 through 1992. PATIENTS OR OTHER PARTICIPANTS: Cases who met predetermined criteria for acute epiglottitis identified from hospital discharges and the State Medical Examiner's log of prehospitalization deaths. MAIN OUTCOME MEASURES: Incidence by year and age, clinical presentation, results of diagnostic evaluations, management, and outcome. RESULTS: Four hundred seven cases were identified, 134 in children and 273 in adults. Incidence in children dropped from 38 cases in the first 3 years of the study to 1 case in the last 3 years (p < 0.001). Adult cases increased from 17 in the first 3 years to 69 in the last 3 years (p < 0.001). Seventy-nine percent of adults and 32% of children were treated without an artificial airway. Factors associated with airway obstruction included symptomatic respiratory difficulty, stridor, drooling, shorter duration of symptoms, enlarged epiglottis on radiograph, and Haemophilus influenzae bacteremia (p < 0.001 for each). Twelve patients died (3 children and 9 adults), with all cases of fatal respiratory obstruction occurring within 12 h of presentation. CONCLUSIONS: There have been significant changes in the clinical epidemiology of epiglottitis, which now occurs almost exclusively in adults, often with less severe symptoms and a lower incidence of H influenzae infection. While careful observation is indicated for all patients, the data suggest that those with certain clinical characteristics can be treated safely without an immediate artificial airway.

Alcohol withdrawal: a nationwide survey of inpatient treatment practices.

OBJECTIVE: To describe current practices employed in the inpatient treatment for alcohol withdrawal. DESIGN: Survey. SETTING: Inpatient alcoholism treatment programs in the United States. PARTICIPANTS: Medical directors of 176 (69%) of 257 eligible programs randomly selected from a national listing. RESULTS: The medical directors estimated that of all inpatients treated for alcohol withdrawal at the programs, 68% received one of the following medications. Benzodiazepines, including the long-acting chlordiazepoxide (33%) and diazepam (16%), and less frequently the short-acting oxazepam (7%) and lorazepam (4%), were the most commonly used agents. Barbiturates (11%), phenytoin (10%), clonidine (7%), beta-blockers (3%), carbamazepine (1%), and antipsychotics (1%) were less frequently given. Drug was most often given on a fixed dosing schedule with additional medication "as needed" (52% of the programs). Only 31% of the programs routinely used a standardized withdrawal severity scale to monitor patients. Mean duration of sedative treatment was three days; inpatient treatment, four days. Use of fixed-schedule regimens was associated with longer sedative treatment (mean four vs three days, p < 0.01). Northeast census region location and psychiatrist program director were significantly associated with longer sedative and inpatient treatment duration. CONCLUSIONS: The most commonly reported regimen for alcohol withdrawal included three days of long-acting benzodiazepines on a fixed schedule with additional medication "as needed." Standardized monitoring of the severity of withdrawal was not common practice. The directors reported using a variety of other regimens, some not known to prevent the major complications of withdrawal. Although geographic location and director specialty were significantly associated with treatment duration, much of the variation in treatment for alcohol withdrawal remains unexplained.

Late-onset seizures in alcohol withdrawal.

PURPOSE: To describe the clinical characteristics of alcohol withdrawal seizures in patients treated with a standardized protocol of short-acting benzodiazepines. METHODS: Grand mal seizures were prospectively identified in a cohort of 1044 patients consecutively admitted to an inpatient alcohol detoxification unit at a Veterans Affairs Medical Center. All patients received a 72-hr structured taper of oxazepam with additional oxazepam given without limit in amount and duration in response to alcohol withdrawal symptoms. RESULTS: Eleven seizures occurred for an overall rate of 1.1%. All were single grand mal seizures. Seizures occurred from 52 to 306 hr after admission, with a mean of 122 hr (5 days). A consistent relationship between the seizures and the cessation of oxazepam was noted, with peak incidence occurring 12-48 hr after the last oxazepam dose. In no case did recurrent withdrawal symptoms or delirium tremens develop after the seizure. Patients with seizures were slightly older, more likely to have had withdrawal seizures before (50% vs. 13%, p = 0.03), and had a more severe withdrawal course than controls. CONCLUSIONS: Seizures continued to occur at a low but measurable rate in alcohol withdrawal treated with a short-acting benzodiazepine. Clinical characteristics of the seizures are different from that classically described in untreated patients, with the seizures being closely related to the cessation of oxazepam rather than the cessation of alcohol.

Treatment of crack-cocaine-induced compulsive behavior with trazodone.

Foraging is a compulsive behavior of searching for pieces of crack cocaine that the individual believes might have been accidentally misplaced. Three clinical cases of compulsive foraging behavior associated with crack cocaine are described. Due to the development of side effects secondary to the antidepressant desipramine, the patients were switched to the antidepressant trazodone. The use of trazodone led to remission of the foraging behavior. The authors hypothesize this remission was due to trazodone serotonin reuptake inhibitory action. In all three cases, the patients did not relapse into abusing crack cocaine.

Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial.

OBJECTIVE: To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal. DESIGN: A randomized double-blind, controlled trial. SETTING: An inpatient detoxification unit in a Veterans Affairs medical center. PATIENTS: One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal. INTERVENTION: Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptom-triggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal. MAIN OUTCOME MEASURES: Duration of medication treatment and total chlordiazepoxide administered. RESULTS: The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-schedule group (P < .001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P < .001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens. CONCLUSIONS: Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.

Teaching physical diagnosis in the nursing home: a prospective, controlled trial.

STUDY OBJECTIVE: To investigate the suitability of the nursing home as a site for teaching physical diagnosis to second-year medical students. DESIGN: Prospective comparison of teaching sessions in the nursing home to concurrent control sessions in acute care wards. SETTING: Nursing Home Care Unit (NHCU) and acute care hospital wards of a Veterans Affairs Medical Center. PATIENTS: Sessions with 38 NHCU patients and 68 hospital patients. MEASUREMENTS AND MAIN RESULTS: Patient interviews and student questionnaires were used to obtain responses on a 1-10 scale (1 = poor, 10 = excellent). Patient responses were very favorable in both settings for overall quality of experience (mean score NHCU vs control: 8.8 vs 8.6) and willingness to participate again (8.4 vs 8.2). Student ratings showed no significant differences for patient attitude (7.4 vs 8.4) or quality of exam (7.2 vs 7.7) while quality of history (6.0 vs 7.6) and overall quality of session (7.6 vs 8.6) were rated higher (P less than 0.05) for the control sessions. Students rated both environments highly (8.6 vs 8.4) but reported that fewer NHCU sessions were interrupted (15% vs 25%) or disrupted by noise (6% vs 30%, P less than 0.005). CONCLUSIONS: Advantages of the nursing home include readily available patients who view participation favorably, instructive physical findings, and a suitable environment. However, students rate the quality of the histories obtained there lower. This problem could be addressed by more careful patient selection and greater emphasis by course instructors on other goals of the history in addition to exploring the chief complaint.