Abstract Background context The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy ...is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder. Purpose To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy. Study design Systematic review and evidence-based clinical guideline. Methods This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline. Results Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Conclusions The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.
Abstract Background context The North American Spine Society (NASS) Evidence-Based Clinical Guideline on the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders provides ...evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of cervical radiculopathy from degenerative disorders. The guideline addresses these questions based on the highest quality clinical literature available on this subject as of May 2009. The guideline’s recommendations assist the practitioner in delivering optimum efficacious treatment of and functional recovery from this common disorder. Purpose Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with cervical radiculopathy from degenerative disorders. Study design Systematic review and evidence-based clinical guideline. Methods This report is from the Cervical Radiculopathy from Degenerative Disorders Work Group of the NASS’ Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subjects of this report. A literature search addressing each question using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional evidence-based databases. The relevant literature was then independently rated by a minimum of three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline. Results Eighteen clinical questions were formulated, addressing issues of natural history, diagnosis, and treatment of cervical radiculopathy from degenerative disorders. The answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence. Conclusions A clinical guideline for cervical radiculopathy from degenerative disorders has been created using the techniques of evidence-based medicine and best available evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site ( www.spine.org ) and will remain updated on a timely schedule.
Abstract Background context The evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides ...evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder. Purpose Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis. Study design Systematic review and evidence-based clinical guideline. Methods This report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline. Results Sixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions A clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site ( www.spine.org ) and will remain updated on a timely schedule.
Prenatal Screening for Fetal Aneuploidy Summers, Anne M., MD; Langlois, Sylvie, MD; Wyatt, Phil, MD, PhD ...
Journal of obstetrics and gynaecology Canada,
02/2007, Letnik:
29, Številka:
2
Journal Article
Recenzirano
Abstract Objective To develop a Canadian consensus document withrecommendations on maternal screening for fetal aneuploidy(e.g., Down syndrome and trisomy 18) in pregnancy. Options Pregnancy ...screening for fetal aneuploidy started in the mid1960s, using maternal age as the screening test. Newdevelopments in maternal serum and ultrasound screening havemade it possible to offer all pregnant patients a non-invasivescreening test to assess their risk of having a fetus with Downsyndrome or trisomy18 to determine whether invasive prenataldiagnosis tests are necessary. This document will review theoptions available for non-invasive screening and makerecommendations for Canadian patients and health care workers. Outcomes To offer non-invasive screening for Down syndrome ortrisomy 18 to all pregnant women. Invasive prenatal diagnosiswould be limited to women who screen above a set risk cut-offlevel on non-invasive screening or pregnant women who will be 40years at time of delivery who, after counselling, chose to go directlyto amniocentesis/chorionic villi sampling (CVS). Currently availablenon-invasive screening options include maternal age combined with (1) first trimester screening (FTS) (nuchal translucency,maternal serum biochemical markers); (2) second trimester serumscreening; or (3) two-step integrated screening, which includes firstand second trimester serum screening with or without nuchaltranslucency (IPS, Serum IPS, contingent and sequential). Theseoptions are reviewed and recommendations are made. Evidence A MEDLINE search was carried out to identify papersrelated to this topic that were published between 1982 and 2006.Practices across Canada were surveyed. A consensus documentwas drafted and reviewed by committee members. Values The quality of evidence and classification ofrecommendations followed discussion and consensus by thecombined committees of SOGC (Genetics, Diagnostic Imaging)and CCMG (Prenatal Diagnosis). Benefits, Harms, Costs These guidelines are intended to reduce thenumber of amniocenteses done when maternal age is the onlyindication. This will have the benefit of reducing the numbers ofnormal pregnancies lost because of complications of invasiveprocedures. Any screening test has an inherent false positive rate,which may result in undue anxiety. A detailed cost-benefit analysisof the implementation of this guideline has not been done, sincethis would require health surveillance and research and healthresources not presently available; however, these factors need tobe evaluated in a prospective approach by provincial and territorialinitiatives. Recommendations 1. All pregnant women in Canada, regardless of age, should beoffered, through an informed consent process, a prenatalscreening test for the most common clinically significant fetalaneuploidies in addition to a second trimester ultrasound fordating, growth, and anomalies. (I-A) 2. Maternal age screening is a poor minimum standard for prenatalscreening for aneuploidy and should be removed as an indicationfor invasive testing. Amniocentesis/chorionic villi sampling (CVS)should not be provided without multiple marker screening resultsexcept for women over the age of 40. Patients should becounselled accordingly. (I-A) 3. In 2007, as a minimum standard, any prenatal screen offered toCanadian women should have a 75% detection rate with no morethan a 5% false positive rate for Down syndrome. The performanceof the screen should be substantiated by annual audit. (III-B) 4. First trimester nuchal translucency should be interpreted for riskassessment only when performed by sonographers/sonologiststrained and accredited to provide this service and with ongoingquality assurance. (II-2A) It should not be offered as a screenwithout biochemical markers except in the context of multiplegestation pregnancies. (I-A) 5. For women who undertake first trimester screening (FTS), secondtrimester serum alpha fetoprotein (AFP) screening and/orultrasound examination is recommended to screen for open neuraltube defect (ONTD). (II-1A) 6. First trimester screening (FTS), the first step of integratedscreening (with or without nuchal translucency), contingent, andsequential screening are performed in an early and relativelynarrow time window. Timely referral is critical to ensure women areable to undergo the type of screening test they have chosen. (II-1A) 7. Soft markers or anomalies in the 18- to 20-week ultrasound can beused to modify the a priori risk of aneuploidy established by age orprior screening provided the scan is undertaken in an establishedcentre performing tertiary level ultrasound. In the absence ofultrasound soft markers or anomalies, a negative likelihood ratio of0.5 should be used. (II-2B) Evaluation of the fetal nasal bone in thefirst trimester remains technically difficult and should not beincorporated as a screen until locally established as an effectiverisk assessment tool. (III-D) 8. Health care providers should be aware of the screening modalitiesavailable in their province or territory. (III-B) 9. Screening programs should be implemented with resources thatsupport audited screening and diagnostic laboratory services,ultrasound, genetic counselling services, patient and health careprovider education, and high quality diagnostic testing, as well asresources for administration, annual clinical audit, and datamanagement. In addition, there must be the flexibility and fundingto adjust the program to new technology and protocols. (II-3B) 10. Screening programs should show respect for the needs and qualityof life of persons with disabilities. Counselling should benondirective and should respect a woman’s choice to accept or torefuse any or all of the testing or options offered at any point in theprocess. (III-I) 11. By 2008, screening programs should aim to provide a screen that,as a minimum, offers women who present in first trimester adetection rate of 75% for Down syndrome, with no more than a 3%false positive rate. (III-B)
The Axial Double Probe (ADP) instrument measures the DC to ∼100 kHz electric field along the spin axis of the Magnetospheric Multiscale (MMS) spacecraft (Burch et al., Space Sci. Rev.,
2014, this ...issue
), completing the vector electric field when combined with the spin plane double probes (SDP) (Torbert et al., Space Sci. Rev.,
2014, this issue
, Lindqvist et al., Space Sci. Rev.,
2014, this issue
). Two cylindrical sensors are separated by over 30 m tip-to-tip, the longest baseline on an axial DC electric field ever attempted in space. The ADP on each of the spacecraft consists of two identical, 12.67 m graphite coilable booms with second, smaller 2.25 m booms mounted on their ends. A significant effort was carried out to assure that the potential field of the MMS spacecraft acts equally on the two sensors and that photo- and secondary electron currents do not vary over the spacecraft spin. The ADP on MMS is expected to measure DC electric field with a precision of ∼1 mV/m, a resolution of ∼25 μV/m, and a range of ∼±1 V/m in most of the plasma environments MMS will encounter. The Digital Signal Processing (DSP) units on the MMS spacecraft are designed to perform analog conditioning, analog-to-digital (A/D) conversion, and digital processing on the ADP, SDP, and search coil magnetometer (SCM) (Le Contel et al., Space Sci. Rev.,
2014, this issue
) signals. The DSP units include digital filters, spectral processing, a high-speed burst memory, a solitary structure detector, and data compression. The DSP uses precision analog processing with, in most cases, >100 dB in dynamic range, better that −80 dB common mode rejection in electric field (
E
) signal processing, and better that −80 dB cross talk between the
E
and SCM (
B
) signals. The A/D conversion is at 16 bits with ∼1/4 LSB accuracy and ∼1 LSB noise. The digital signal processing is powerful and highly flexible allowing for maximum scientific return under a limited telemetry volume. The ADP and DSP are described in this article.
Abstract Background Context The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to ...provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder. Purpose To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis. Study Design Systematic review and evidence-based clinical guideline. Methods This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I–IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Results Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site ( www.spine.org ) and will remain updated on a timely schedule.
Abstract Background context The objective of the North American Spine Society (NASS) evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (DLSS) is ...to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of DLSS. The guideline is intended to reflect contemporary treatment concepts for symptomatic DLSS as reflected in the highest quality clinical literature available on this subject as of April 2006. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment, and functional recovery from this spinal disorder. Purpose To provide an evidence-based tool that assists practitioners in improving the quality and efficiency of care delivered to patients with DLSS. Study design/setting Evidence-based clinical guideline. Methods This report is from the Spinal Stenosis Work Group of the NASS Clinical Guidelines Committee. The work group comprised medical, diagnostic, interventional, and surgical spinal care specialists, all of whom were trained in the principles of evidence-based analysis. In the development of this guideline, the work group arrived at a consensus definition of a working diagnosis of lumbar spinal stenosis by use of a modification of the nominal group technique. Each member of the group formatted a series of clinical questions to be addressed by the group and the final list of questions agreed on by the group is the subject of this report. A literature search addressing each question and using a specific literature search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature to answer each clinical question was then independently rated by at least two reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Any discrepancies in evidence levels among the initial raters were resolved by at least two additional members' review of the reference and independent rating. Final grades of recommendation for the answer to each clinical question were arrived at in face-to-face meetings among members of the work group using the NASS-adopted standardized grades of recommendation. When Levels I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Results Eighteen clinical questions were asked, addressing issues of prognosis, diagnosis, and treatment of DLSS. The answers to these 18 clinical questions are summarized in this document along with their respective levels of evidence and grades of recommendation in support of these answers. Conclusions A clinical guideline for DLSS has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid both practitioners and patients involved with the care of this disease. The entire guideline document including the evidentiary tables, suggestions for future research, and all references is available electronically at the NASS Web site ( www.spine.org ) and will remain updated on a timely schedule.
Although two-dose mRNA vaccination provides excellent protection against SARS-CoV-2, there is little information about vaccine efficacy against variants of concern (VOC) in individuals above eighty ...years of age
. Here we analysed immune responses following vaccination with the BNT162b2 mRNA vaccine
in elderly participants and younger healthcare workers. Serum neutralization and levels of binding IgG or IgA after the first vaccine dose were lower in older individuals, with a marked drop in participants over eighty years old. Sera from participants above eighty showed lower neutralization potency against the B.1.1.7 (Alpha), B.1.351 (Beta) and P.1. (Gamma) VOC than against the wild-type virus and were more likely to lack any neutralization against VOC following the first dose. However, following the second dose, neutralization against VOC was detectable regardless of age. The frequency of SARS-CoV-2 spike-specific memory B cells was higher in elderly responders (whose serum showed neutralization activity) than in non-responders after the first dose. Elderly participants showed a clear reduction in somatic hypermutation of class-switched cells. The production of interferon-γ and interleukin-2 by SARS-CoV-2 spike-specific T cells was lower in older participants, and both cytokines were secreted primarily by CD4 T cells. We conclude that the elderly are a high-risk population and that specific measures to boost vaccine responses in this population are warranted, particularly where variants of concern are circulating.
Study objective We assess the diagnostic accuracy of emergency physician–performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical ...pathology. Methods We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. Results Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval CI 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). Conclusion The test characteristics of emergency physician–performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.
Study objective Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether ...illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons. Methods From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 lowest to 13 highest) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes. Results The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval CI 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period. Conclusion Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.
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