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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. [ABSTRACT FROM AUTHOR]

Importance: Primary care panel size plays an increasing role in measuring primary care provider (ie, physicians and advanced practice providers, which include nurse practitioners and physician assistants) workload, setting practice capacity, and determining pay and can influence quality of care, access, and burnout. However, reported panel sizes vary widely., Objective: To identify how panels are defined, the degree of variation in these definitions, the consequences of different definitions of panel size, and research on strengths of different approaches., Evidence Review: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, MEDLINE, Web of Science, Embase, and Dissertations and Theses Global databases were searched from inception to April 28, 2021, for subject headings and text words to capture concepts of primary care panel size. Article review and data abstraction were performed independently by 2 reviewers. Main outcomes reported included rules for adding or removing patients from panels, rules for measuring primary care provider resources, consequences of different rules on reported panel size, and research on advantages and disadvantages of different rules., Findings: The literature search yielded 1687 articles, with 294 potentially relevant articles and 74 containing relevant data. Specific practices were identified from 29 health care systems and 5 empanelment implementation guides. Patients were most commonly empaneled after 1 primary care visit (24 of 34 [70.6%]), but some were empaneled only after several visits (5 [14.8%]), enrollment in a health plan (4 [11.8%]) or any visit to the health care system (1 [3.0%]). Patients were removed when no visit had occurred in a specified look-back period, which varied from 12 to 42 months. Regarding primary care provider resources, half of organizations assigned advanced practice providers independent panels and half had them share panels with a physician, increasing the physician's panel by 50% to 100%. Analyses demonstrated that changes in individual rules for adding patients, removing patients, or estimating primary care provider resources could increase reported panel size from 20% to 100%, without change in actual primary care provider workload. No research was found investigating advantages of different definitions., Conclusions and Relevance: Much variation exists in how panels are defined, and this variation can have substantial consequences on reported panel size. Research is needed on how to define primary care panels to best identify active patients, which could contribute to a widely accepted standard approach to panel definition.

Background: Tissue plasminogen activator (tPA) is a serine protease with thrombolytic-fibrinolytic activity. In the anterior segment of the eye, it has been used to lyse blood and fibrin clots immediately following trabeculectomy., Objective: To review our experience using tPA to revive previously functional but newly failing blebs following secondary surgical procedures (cataract extraction or penetrating keratoplasty)., Methods: A retrospective medical record review of all eyes receiving tPA to revive a failing bleb after a later anterior segment surgery was performed. Blebs were functional for at least 9 months before tPA, 12.5 microg, was injected into the anterior chamber. Eyes had longer than 6 months of follow-up after tPA use., Results: Six eyes that had undergone phacoemulsification and 1 that had undergone penetrating keratoplasty were identified. Before the secondary surgery, blebs had been in place for 20.4 +/- 9.3 months, with an intraocular pressure of 10.7 +/- 3.6 mm Hg. New bleb failure in these eyes was observed following phacoemulsification or penetrating keratoplasty between postoperative days 4 and 14, with the intraocular pressure increasing to 27.7 +/- 9.5 mm Hg. One day after tPA use, the intraocular pressure had decreased to 11.0 +/- 3.7 mm Hg (P =.002). In 5 of the 7 patients, the bleb height improved following tPA use. The final intraocular pressure was 10.7 +/- 3.6 mm Hg at a follow-up of 13.4 +/- 6.4 months. (All data are given as mean +/- SD.), Conclusion: Tissue plasminogen activator can be a useful adjunct for reviving newly failing blebs after other anterior segment surgery.

Objective: To review the effect of phacoemulsification surgery in eyes with chronic hypotony following trabeculectomy with mitomycin C., Design: Retrospective analysis of all eyes that underwent phacoemulsification surgery for symptomatic cataracts and had a preoperative diagnosis of chronic hypotony (intraocular pressure [IOP]

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.

Objective: To compare the 350-mm2 Baerveldt implant with the double-plate Molteno implant in the treatment of eyes with complicated glaucoma., Design: Retrospective chart review of a consecutive series of drainage implants., Setting: University-based referral practice., Patients: Thirty-four consecutive patients (37 eyes) undergoing glaucoma drainage device implantation because of uncontrolled, complicated glaucoma., Intervention: Eighteen eyes underwent 350-mm2 Baerveldt implantation and 19 eyes underwent double-plate Molteno implantation., Main Outcome Measures: Intraocular pressure (IOP) control, visual acuity outcome, and complication rate., Results: Mean preoperative IOP was 30.2 mm Hg in the Baerveldt group, with an average of 2.7 antiglaucoma medications, and 28.4 mm Hg in the Molteno group, with an average of 2.4 antiglaucoma medications. With an average follow-up of 11.3 months (range, 5 to 16 months), mean IOP at the final visit was 13.1 mm Hg (range, 7 to 21 mm Hg) in the Baerveldt group, with an average of 1.3 medications, and 13.4 mm Hg (range, 8 to 25 mm Hg) in the Molteno group, with an average of 0.8 medications. Final IOP was between 7 and 19 mm Hg in 16 of 18 Baerveldt eyes and in 17 of 19 Molteno eyes. Visual acuity (when it could be checked) remained stable (+/- 2 Snellen lines) in 17 of 17 eyes in the Baerveldt group and in 17 of 19 eyes in the Molteno group. Complications in the Baerveldt group included two cases (11%) of flat anterior chamber after stent removal, one case (6%) of intermittently symptomatic diplopia, and one case (6%) of endophthalmitis. In the Molteno group there were two graft failures (11%) and one eye (5%) with loss of central field., Conclusions: Both types of drainage implants provide excellent postoperative IOP control. Early stent removal should be avoided if possible in eyes with Baerveldt implants.

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.

A randomized, prospective study was undertaken to compare the results of the double-plate Molteno implant with those of the anterior chamber tube shunt to encircling band (ACTSEB) procedure, described by Schocket, for eyes with complicated glaucoma. One surgeon performed all the procedures. For statistical analysis there were 21 eyes in the ACTSEB group and 19 eyes in the Molteno group, with at least 6 months of follow-up (mean follow-up, 26 months; range, 6 to 49 months). Eyes with aphakia/pseudophakia, uveitis, previous penetrating keratoplasty, previous unsuccessful trabeculectomy, and neovascular glaucoma were evenly distributed between the two groups. Mean preoperative intraocular pressures in the ACTSEB and Molteno groups were 35.2 and 34.6 mm Hg, respectively. With the exclusion of one phthisical eye in each group final mean intraocular pressure in the ACTSEB group was 15.1 mm Hg, with a mean of 0.43 medications, and 14.4 mm Hg, with a mean of 0.95 medications, in the Molteno group. Seven (33%) of 21 eyes and 13 (68%) of 19 eyes in the ACTSEB and Molteno groups, respectively, were receiving additional antiglaucoma medication at the most recent visit (P = .027). Final visual acuity was stable (within one Snellen line of baseline visual acuity) or improved in 10 (48%) of 21 eyes in the ACTSEB group compared with 13 (68%) of 19 eyes in the Molteno group. Complications or inadequate pressure control requiring further surgical intervention were seen in nine (47%) of 19 eyes in the Molteno group and 12 (57%) of 21 eyes in the ACTSEB group.(ABSTRACT TRUNCATED AT 250 WORDS)