The document discusses guidelines for clinical practice in psychiatry. It covers the development and evaluation of guidelines. Guideline development involves establishing a group with relevant expertise, systematically reviewing evidence, developing recommendations, and updating over time. Evaluation tools like AGREE assess guidelines across several domains including rigor of development, applicability, and independence. Most guidelines have room for improvement in areas like stakeholder involvement and addressing implementation. Indian guidelines aim to be relevant to local practice but could better integrate Indian research evidence.
Premature ejaculation (PE), the most common male health disorder found now a days. It can be defined as Lack of control of ejaculation which always occurs prior to or within about 1 minute of conjugation. Pre mature ejaculation is ejaculation that occur too early on slightest excitement. It can make a unhappy and frustrated married life. In severe cases it can even ruin the mirage life. Occasionally loss of control does not mean he has the problem of premature ejaculation. But every time ejaculation in 1 minute cannot be considered as normal. In young age group of nightly emission after dream or nocturnal emission is also considered as a part of early ejaculation. Dribbling of prostatic fluid during urination or stool is also considered under premature ejaculation. Premature Ejaculation may co occur with erectile dysfunction, with almost half of men suffering from premature ejaculation experiencing erectile dysfunction as well.
Ejaculation is comprised of three stages of the male sexual response cycle, namely emission, ejection, and orgasm.
1. Emission - Bladder neck closure & deposition of seminal fluid into posterior urethra
2. Ejection - Expulsion of seminal fluid from the urethra
3. Orgasm - A sensory experience associated with all these events
There is no such strict ejaculation time period. But still if the ejaculation is occuring in 5 to 8 minutes can be considered as normal ejaculation. But if the ejaculation is occurring within 1 minute cannot be called as healthy and normal ejaculation. Another thing if both the partner are happy in that short period also cannot be called as pre mature.
• Ejaculation time more than 4 minutes - Normal
• Ejaculation time less than 1 minute - Pre mature ejaculation
• Ejaculation time 1 - 1.5 minutes - Probable pre mature ejaculation
Causes of premature ejaculation
There are various pre disposing factors that causes premature ejaculation.
• Infrequent mixing of couple
• Over anxiety and depression state of mind
• Bad habits of artificial way of ejaculation in teen age is also one of the most common cause of premature ejaculation
• Living in a stress full and pressure packed life style
• Person’s feeling of guilty or self -reproach and blame.
• Certain drugs used for psychiatric or behavioural problem
Homeopathic Treatment for Premature ejaculation
• Homeopathy has an effective and promising treatment in pre mature ejaculation or early ejaculation problem. It is because homeopathy treats the cause of any health problems rather than the symptoms.
• Homeopathic treatment lengthens the ejaculation time.
• It also helps to cure the other health problem associated to Pre mature ejaculation.
• It also cure the physical and mental exhaustion associated with PE due to over mental stressed condition
• Homeopathic treatment cures the anxiety condition and guilty feeling symptoms associated with PE
• Homeopathic treatment cures the night emission too occurs in young mass.
Premature ejaculation (PE), the most common male health disorder found now a days. It can be defined as Lack of control of ejaculation which always occurs prior to or within about 1 minute of conjugation. Pre mature ejaculation is ejaculation that occur too early on slightest excitement. It can make a unhappy and frustrated married life. In severe cases it can even ruin the mirage life. Occasionally loss of control does not mean he has the problem of premature ejaculation. But every time ejaculation in 1 minute cannot be considered as normal. In young age group of nightly emission after dream or nocturnal emission is also considered as a part of early ejaculation. Dribbling of prostatic fluid during urination or stool is also considered under premature ejaculation. Premature Ejaculation may co occur with erectile dysfunction, with almost half of men suffering from premature ejaculation experiencing erectile dysfunction as well.
Ejaculation is comprised of three stages of the male sexual response cycle, namely emission, ejection, and orgasm.
1. Emission - Bladder neck closure & deposition of seminal fluid into posterior urethra
2. Ejection - Expulsion of seminal fluid from the urethra
3. Orgasm - A sensory experience associated with all these events
There is no such strict ejaculation time period. But still if the ejaculation is occuring in 5 to 8 minutes can be considered as normal ejaculation. But if the ejaculation is occurring within 1 minute cannot be called as healthy and normal ejaculation. Another thing if both the partner are happy in that short period also cannot be called as pre mature.
• Ejaculation time more than 4 minutes - Normal
• Ejaculation time less than 1 minute - Pre mature ejaculation
• Ejaculation time 1 - 1.5 minutes - Probable pre mature ejaculation
Causes of premature ejaculation
There are various pre disposing factors that causes premature ejaculation.
• Infrequent mixing of couple
• Over anxiety and depression state of mind
• Bad habits of artificial way of ejaculation in teen age is also one of the most common cause of premature ejaculation
• Living in a stress full and pressure packed life style
• Person’s feeling of guilty or self -reproach and blame.
• Certain drugs used for psychiatric or behavioural problem
Homeopathic Treatment for Premature ejaculation
• Homeopathy has an effective and promising treatment in pre mature ejaculation or early ejaculation problem. It is because homeopathy treats the cause of any health problems rather than the symptoms.
• Homeopathic treatment lengthens the ejaculation time.
• It also helps to cure the other health problem associated to Pre mature ejaculation.
• It also cure the physical and mental exhaustion associated with PE due to over mental stressed condition
• Homeopathic treatment cures the anxiety condition and guilty feeling symptoms associated with PE
• Homeopathic treatment cures the night emission too occurs in young mass.
Analysis of Variance and Repeated Measures DesignJ P Verma
This presentation discusses the basic concept used in analysis of variance and it shows the difference between independent measures ANOVA and Repeated measures ANOVA
By 2030 one-fifth of the U.S. population will be 65 or older. Older populations are "not what they used to be" and need not support the myths about old age. This powerpoint talks about the upside of growing older.
Analysis of Variance and Repeated Measures DesignJ P Verma
This presentation discusses the basic concept used in analysis of variance and it shows the difference between independent measures ANOVA and Repeated measures ANOVA
By 2030 one-fifth of the U.S. population will be 65 or older. Older populations are "not what they used to be" and need not support the myths about old age. This powerpoint talks about the upside of growing older.
Physiotherapist or Physical therapists are important health providers and can contribute to enhanced outcomes in many common musculoseletal disorders including osteoarthritis, ACL injuries, tendinopathies, such as rotator cuff disorders, tennis elbow and achilles tendinopathy and muscle tears
Evidence based practice (EBP) in physiotherapy Saurab Sharma
This presentation is the classroom lecture for undergraduate physiotherapy students whom I teach at Kathmandu University School of Medical Sciences in Nepal. This is an introductory lecture. Students carry on with steps of EBP in the years to come during the student life and use it for their presentations and clinical learning placement.
Other students too may benefit. I highly encourage other students, especially in some parts of India where EBP is not taught, and is reserved for Master's degree program. I completely disagree with this concept, as EBP is the pillar of a responsible physiotherapy practice. Early it starts, better it is.
Standard of care / Standard of Practice / Clinical Guideline/ Clinical Pathway Naz Usmani
A very brief presentation to differentiate between clinical process improvement practice , guideline and pathway .
I have reflected on the basic differences between them .
At the end of this presentation you will be able to:
Define evidence-based practice
Describe process & outline steps of EBP
Understand PICO elements & search strategy
Identify resources to support EBP
The focus of this presentation is nursing practice, although it is still of value to physicians and other health care professionals.
Utilización de la evidencia cualitativa para mejorar la inclusión de las pref...GuíaSalud
Tercera intervención de la Mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Simon Lewin
Evidence-Based Professional Nursing PracticeChapte.docxturveycharlyn
Evidence-Based
Professional
Nursing Practice
Chapter 10
Evidence-Based Practice:
What Is It?
• Evidence-based practice (EBP) is a
framework used by nurses and other
healthcare professionals to deliver optimal
health care through the integration of best
current evidence, clinical expertise, and
patient/family values
Why Is EBP Relevant in Nursing? (1 of 2)
• Helps resolve problems in the clinical setting
• Results in effective patient care and better
outcomes
• Contributes to the science of nursing through
the introduction of innovation to practice
• Keeps practice current and relevant by helping
nurses deliver care based upon current best
research
Why Is EBP Relevant in Nursing? (2 of 2)
• Decreases variations in nursing care and
increases confidence in decision making
• Supports Joint Commission on Accreditation
of Healthcare Organizations (JCAHO)-
readiness since policies and procedures are
current and include the latest research
• Supports high quality patient care and
achievement of Magnet status
Steps in the EBP Process (1 of 2)
• Cultivate a spirit of inquiry and culture of EBP
among nurses and within the organization
• Identify an issue and ask the question
• Search for and collect the most relevant and
best evidence to answer the clinical question
Steps in the EBP Process (2 of 2)
• Critically appraise the evidence and synthesize
the evidence
• Integrate evidence with clinical expertise and
patient preferences to make the best clinical
decision
• Evaluate the outcome of any EBP change
• Disseminate the outcomes of the change
Barriers to EBP in Nursing (1 of 3)
• Lack of value for research in practice
• Difficulty in changing practice
• Lack of administrative support
• Lack of knowledgeable mentors
• Insufficient time
• Lack of education about the research process
• Lack of awareness about research or EBP
Barriers to EBP in Nursing (2 of 3)
• Research reports/articles not readily available
• Difficulty accessing research reports and articles
• No time on the job to read research
• Complexity of research reports
• Lack of knowledge about EBP
• Lack of knowledge about the critique of articles
Barriers to EBP in Nursing (3 of 3)
• Feeling overwhelmed by the process
• Lack of sense of control over practice
• Lack of confidence to implement change
• Lack of leadership, motivation, vision,
strategy, or direction among managers
Promoting EBP: Individual Nurse
• Educate yourself about EBP
• Conduct face-to-face or online journal clubs,
share new research reports and guidelines with
peers, and provide support to other nurses
• Share your results through posters, newsletters,
unit meetings, or a published article
• Adopt a reflective and inquiring approach to
practice
Strategies to Promote EBP:
Organizations
• Specific identification of the facilitators and
barriers to EBP
• Education and training to improve
knowle.
Evidence-Based Professional Nursing PracticeChapte.docxelbanglis
Evidence-Based
Professional
Nursing Practice
Chapter 10
Evidence-Based Practice:
What Is It?
• Evidence-based practice (EBP) is a
framework used by nurses and other
healthcare professionals to deliver optimal
health care through the integration of best
current evidence, clinical expertise, and
patient/family values
Why Is EBP Relevant in Nursing? (1 of 2)
• Helps resolve problems in the clinical setting
• Results in effective patient care and better
outcomes
• Contributes to the science of nursing through
the introduction of innovation to practice
• Keeps practice current and relevant by helping
nurses deliver care based upon current best
research
Why Is EBP Relevant in Nursing? (2 of 2)
• Decreases variations in nursing care and
increases confidence in decision making
• Supports Joint Commission on Accreditation
of Healthcare Organizations (JCAHO)-
readiness since policies and procedures are
current and include the latest research
• Supports high quality patient care and
achievement of Magnet status
Steps in the EBP Process (1 of 2)
• Cultivate a spirit of inquiry and culture of EBP
among nurses and within the organization
• Identify an issue and ask the question
• Search for and collect the most relevant and
best evidence to answer the clinical question
Steps in the EBP Process (2 of 2)
• Critically appraise the evidence and synthesize
the evidence
• Integrate evidence with clinical expertise and
patient preferences to make the best clinical
decision
• Evaluate the outcome of any EBP change
• Disseminate the outcomes of the change
Barriers to EBP in Nursing (1 of 3)
• Lack of value for research in practice
• Difficulty in changing practice
• Lack of administrative support
• Lack of knowledgeable mentors
• Insufficient time
• Lack of education about the research process
• Lack of awareness about research or EBP
Barriers to EBP in Nursing (2 of 3)
• Research reports/articles not readily available
• Difficulty accessing research reports and articles
• No time on the job to read research
• Complexity of research reports
• Lack of knowledge about EBP
• Lack of knowledge about the critique of articles
Barriers to EBP in Nursing (3 of 3)
• Feeling overwhelmed by the process
• Lack of sense of control over practice
• Lack of confidence to implement change
• Lack of leadership, motivation, vision,
strategy, or direction among managers
Promoting EBP: Individual Nurse
• Educate yourself about EBP
• Conduct face-to-face or online journal clubs,
share new research reports and guidelines with
peers, and provide support to other nurses
• Share your results through posters, newsletters,
unit meetings, or a published article
• Adopt a reflective and inquiring approach to
practice
Strategies to Promote EBP:
Organizations
• Specific identification of the facilitators and
barriers to EBP
• Education and training to improve
knowle ...
Evaluating a pratice guideline is essential given the rapid proliferation of them in the recent times. Here some general principles of evaluation of the guidelines are described with a guideline for panic disorder used in Australia, as an example.
A service improvement focused on frailty using an R&D approach, pop up uni, 3...NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
OHE’s Professor Nancy Devlin has researched, written and spoken widely on the use of the EQ-5D, and related measures, both in her capacity as the Director of Research at the OHE and as Chair of the Executive Committee of the EuroQol Group.
In May, Nancy was invited to participate in the “Workshop on measuring patient-reported outcomes using the EQ-5D”, which was organised by the Swedish National Board of Health and Welfare in collaboration with the EuroQol Group. The workshop brought together policy makers and researchers in Sweden interested in measuring patients’ health outcomes.
Sweden has included the EQ-5D in some of its quality registries and in population health surveys for many years. The Swedish National Board of Health and Welfare now is exploring whether and how to extend use of patient reported outcomes measures in the health care system, including the EQ-5D, to both monitor the quality of providers and services and to facilitate health technology appraisal.
Nancy’s talk, shown below, introduced the EQ-5D instrument; discussed how data from it can be analysed; identified some of the challenges in analysis; and commented on the future of outcomes measurement.
Similar to Development and Evaluation of clinical practice guideline (CPG) in psychiatry (20)
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
3. Introduction
• The history of Good Clinical Practice statute traces back to The
Hippocratic Oath- ethical code it is primarily known for its edict to
do no harm to the patient.
• Clinical practice guidelines are one of the foundations of efforts to
improve health care.
• The modern age of guidelines began with a 1992. Institute of
Medicine (IOM) report
• Defined guidelines as “systematically developed statements to
assist practitioner and patient decisions about appropriate health
care for specific clinical circumstances”
• Psychiatry, as a discipline, is relatively new in the field of evidence
based medicine.
4. • Some of the most well-known and widely accepted guidelines
are -
APA guidelines by the American Psychiatric Association
Texas Medication Algorithm Project Group (TMAP)
Patient Outcomes Research Team (PORT)
Canadian treatment guidelines by the Canadian Psychiatric
Association
CANMAT (Canadian Network for Mood and Anxiety
Treatments)
NICE guidelines by National Institute for Clinical Excellence
Maudsley guidelines
5. Why are these guidelines needed?
• Improve the quality of health care.
• Reduce the use of unnecessary, ineffective or harmful
interventions.
• Facilitate the treatment of patients with maximum chance of
benefit, with minimum risk of harm, and at an acceptable cost.
• Principles of good decision making which takes account of patients'
preferences and values, clinicians values and experience, the best
available evidence and the availability of resources.
National Health and medical Research Council (NHMRC) 1999. A guide to the development, implementation and evaluation of clinical practice guidelines.
6. Development of CPG
• Six CPG development handbooks available.
1. Council of Europe
2. National Health and Medical Research Council of Australia
3. National Institute for Health and Clinical Excellence
4. New Zealand Guidelines Group
5. Scottish Intercollegiate Guideline Network
6. World Health Organization (WHO).
7.
8. • Target audiences and their use of guidelines
• Prioritizing topics for guideline development
9. • Guideline group composition and group process-
Technical process (systematic reviews of relevant evidence) and Social
process (interpretation of the results of the systematic review and
development of recommendations)
Sufficient experience Vs Cohesiveness
Optimum size for a small group - between eight and ten people, although
groups of larger size have operated effectively
• Consumer involvement- “incorporate patients’ values, preferences,
knowledge, or perspectives in CPG recommendations”
– incorporating individual patients in guideline development groups;
– a ‘one off ’ meeting with patients;
– a series of workshops with patients;
– incorporating a consumer advocate in guideline development groups
Eccles et al. Implementation Science 2012, 7:60
10. • Managing conflicts of interest (COI) in guideline development-
Financial COI is the best known type of COI and typically a
result of direct financial benefit related to topics discussed or
products recommended in guidelines or personal financial
interests
Intellectual COI is another type of conflict that is increasingly
recognized and results from a guideline group member being
invested in her/her intellectual work
11. • Asserting strength of evidence- Grading of Recommendations,
Assessment, Development and Evaluation (GRADE) approaches
• 5 factors can lower the confidence in an estimate of effect and study
quality:
Study design and execution (risk of bias)
Inconsistency of the evidence across studies
Indirectness of the evidence (including concepts of lack of generalizability,
transferability and external validity)
Lack of precision of the estimate of the effect
Publication bias.
• 3 factors can increase the quality of evidence:
A strong or very strong association;
A dose-effect relationship;
All plausible residual confounding may be working to reduce the
demonstrated effect or increase the effect if no effect was observed.
12.
13. • 4 Factors that influence recommendations-
Quality of the available supporting body of evidence
Balance between benefits and undesirable downsides
Certainty about or variability in values and preferences of
patients
Resource expenditure associated with the management
options
14. Balance between benefits and undesirable downsides
• When the benefits of recommendation >>> downsides - the
recommendation will be strong.
• When the desirable consequences ≈ undesirable consequences - a
weaker recommendation is warranted.
• Relative risk/ hazard ratio/ odds ratio Vs absolute effects for a
specific population or situation
• Desirable and undesirable effects at baseline risk
15. Uncertainty or variability of patient values and preferences
• Clinicians’ understanding of importance of particular outcomes for
patients can differ from that of the patients
• Data about patients’ preferences and values are often limited.
• Alternative management strategies- as a trade-off is always
necessary.
• Transparent explanation facilitates the interpretation of
recommendations
Costs or resource utilization
• Costs are much more variable over time and geographic areas than
are other outcomes
• Higher costs will reduce the likelihood of a strong recommendation
in favor of a particular intervention
• In considering resource allocation- very specific about the setting to
which a recommendation applies and the perspective they took,
i.e., that of a patient, a third party payer or society as a whole.
16. Wording recommendations
• Inform users of guidelines (e.g., clinicians, patients and their family
members, policy makers) about the degree of confidence by
specifying the strength of recommendations.
• Phrasing recommendations in an active voice as clear indications
what specific action should follow- ‘we recommend . . .’ Vs ‘we
suggest . . .’
• Alternatively- ‘clinicians should . . .’ Vs ‘clinicians might . . .’ or ‘we
conditionally recommend . . ..’
• Avoid ambiguous phrases- ‘clinically appropriate’ or ‘if necessary.’
17. Should guideline panels make recommendations in the face of
very low-quality evidence?
• Option of not making a recommendation should be included for all
guideline panels- ‘insufficient evidence to make a recommendation’
category.
• Higher-quality evidence may never be obtained/ physicians need
guidance regardless- transparently lay out the judgments they
make.
18.
19. Evaluation of clinical guidelines
• Numerous guidelines in every disciplines
• Great variability exists in the quality of clinical practice
guidelines
• Need to discriminate high-quality from lower-quality
guidelines.
• 24 appraisal instruments of practice guidelines
20.
21.
22. • The AGREE instrument-
• Based on the Cluzeau instrument
• It has been validated.
• It uses a numerical scoring scale- easier to compare scores.
• easy-to-use, and transparent instrument
• internationally developed and widely accepted,
• “It can possibly serve as a basis for an instrument to evaluate
the methodological quality of clinical pathways. “
24. • The AGREE Instrument is designed to assess guidelines developed by local,
regional, national or international groups or affiliated governmental
organizations. These include:
1. New guidelines
2. Existing guidelines
3. Updates of existing guidelines
• The AGREE Instrument is intended to be used by the following groups:
i) By policy makers to help them decide which guidelines could be
recommended for use in practice.
ii) By guideline developers to follow a structured and rigorous
development methodology and as a self-assessment tool to ensure
that their guidelines are sound.
iii) By health care providers who wish to undertake their own
assessment before adopting the recommendations
25. Structure and content of the AGREE Instrument
AGREE consists of 23 key items organized in six domains. Each domain is
intended to capture a separate dimension of guideline quality.
• Scope and purpose (items 1-3) is concerned with the overall aim of the
guideline, the specific clinical questions and the target patient population.
• Stakeholder involvement (items 4-7) focuses on the extent to which the
guideline represents the views of its intended users.
• Rigour of development (items 8-14) relates to the process used to gather
and synthesize the evidence, the methods to formulate the
recommendations and to update them.
• Clarity and presentation (items 15-18) deals with the language and format
of the guideline.
• Applicability (items 19-21) pertains to the likely organizational, behavioral
and cost implications of applying the guideline.
• Editorial independence (items 22-23) is concerned with the independence
of the recommendations and acknowledgement of possible conflict of
interest from the guideline development group.
26. Document-
• Recommend that you read the guideline and its accompanying
documentation fully before you start the appraisal.
Number of appraisers
• We recommend that each guideline is assessed by at least two appraisers
and preferably four as this will increase the reliability of the assessment.
Response scale
• Each item is rated on a 4-point scale ranging from 4 ‘Strongly Agree’ to 1
‘Strongly Disagree’, with two mid points: 3 ‘Agree’ and 2 ‘Disagree’.
Comments
• There is a box for comments next to each item. You should use this box to
explain the reasons for your responses.
27. Calculating domain scores
Overall assessment
• A section for overall assessment is included at the end of the instrument.
• Contains a series of options ‘Strongly recommend’, ‘Recommend (with
provisos or alterations)’, ‘Would not recommend’ and ‘Unsure’.
28. SCOPE AND PURPOSE
1. The overall objective(s) of the guideline is (are) specifically described.
• Potential health impact of a guideline on society and populations of
patients- Rational prescribing of antidepressants in a cost-effective way
2. The clinical question(s) covered by the guideline is(are) specifically
described.
• Are selective serotonin reuptake inhibitors (SSRIs) more cost-effective
than tricyclic antidepressants (TCAs) in treatment of patients with
depression?
3. The patients to whom the guideline is meant to apply are specifically
described.
• A guideline on the management of depression only includes patients with
major depression, according to the DSM--5 criteria, and excludes patients
with psychotic symptoms and children.
29. STAKEHOLDER INVOLVEMENT
4. The guideline development group includes individuals from all the
relevant professional groups.
• Information about the composition, discipline and relevant expertise of
the guideline development group should be provided.
5. The patients’ views and preferences have been sought.
• For example, the development group could involve patients’
representatives, information could be obtained from patient interviews,
literature reviews of patients’ experiences could be considered by the
group
6. The target users of the guideline are clearly defined.
• For example, the target users for a guideline on headache may include
general practitioners, neurologists, psychiatrist, and psychologist
7. The guideline has been piloted among target users.
• For example, a guideline may have been piloted in one or several primary
care practices or hospitals. This process should be documented
30. RIGOUR OF DEVELOPMENT
8. Systematic methods were used to search for evidence.
• Search terms used, databases of systematic reviews
9. The criteria for selecting the evidence are clearly described.
• Including /excluding criterias
10. The methods used for formulating the recommendations are clearly
described.
• Areas of disagreement and methods of resolving them should be
specified- for example, a voting system, formal consensus techniques (e.g.
Delphi, Glaser techniques).
11. The health benefits, side effects and risks have been considered in
formulating the recommendations.
• These may include: survival, quality of life, adverse effects, and symptom
management or a discussion
31. 12. There is an explicit link between the recommendations and the
supporting evidence.
• Recommendation should be linked with a list of references on which it is
based
13. The guideline has been externally reviewed by experts prior to its
publication.
14. A procedure for updating the guideline is provided.
• For example, a timescale has been given, or a standing panel receives
regularly updated literature searches and makes changes as required.
32. CLARITY AND PRESENTATION
15. The recommendations are specific and unambiguous.
• Recommendation should provide a concrete and precise description of
which management is appropriate in which situation and in what patient
group, as permitted by the body of evidence.
16. The different options for management of the condition are clearly
presented.
• For example, a recommendation on the management of depression may
contain the following alternatives:
• a. Treatment with TCA/ b. Treatment with SSRI/ c. Psychotherapy/
d. Combination of pharmacological and psychological therapy
17. Key recommendations are easily identifiable.
• For example, they can be summarized in a box, typed in bold, underlined
or presented as flow charts or algorithms.
18. The guideline is supported with tools for application.
• For example, a summary document, or a quick reference guide,
educational tools, patients’ leaflets, computer support, and should be
provided with the guideline.
33. APPLICABILITY
19. The potential organizational barriers in applying the recommendations
have been discussed.
• Recommendations may require changes in the current organization of care
within a service or a clinic which may be a barrier to using them in daily
practice.
20. The potential cost implications of applying the recommendations have
been considered.
• For example, there may be a need for more specialized staff, new
equipment, expensive drug treatment. These may have cost implications
for health care budgets. There should be a discussion of the potential
impact on resources in the guideline.
21. The guideline presents key review criteria for monitoring and/or audit
purposes.
• Clearly defined review criteria that are derived from the key
recommendations in the guideline- like follow up of MDD- HAM-D < 7 for 6
months
34. EDITORIAL INDEPENDENCE
22. The guideline is editorially independent from the funding body.
• Explicit statement that the views or interests of the funding body have not
influenced the final recommendations. If it is stated that a guideline was
developed without external funding, then should answer ‘Strongly Agree’.
23. Conflicts of interest of guideline development members have been
recorded.
• For example, this would apply to a member of the development group
whose research on the topic covered by the guideline is also funded by a
pharmaceutical company. There should be an explicit statement that all
group members have declared whether they have any conflict of interest
35. Limitations of the AGREE instrument-
• Does not include criteria addressing how the guideline topic was
selected
• Does not include criteria addressing how the it will be
implemented.
• Does not assess whether systematic methods were used to
appraise the research evidence used to support guideline
recommendations
• Not possible to set thresholds for the scores to classify a clinical
practice guideline as ‘good’ or ‘bad’.
36.
37. • NICE guideline had the highest methodological quality
according to AGREE and the highest scores in five out of six
domains.
• [‘One explanation might be that this guideline was developed
as part of a national policy within an established guideline
programme adequately resourced by the health authorities.’]
• Followed by the second edition of the American Psychiatric
Association (APA) guideline (total score=71)the Royal
Australian and New Zealand College of Psychiatrists guideline
total score= 62)
38.
39. • Most (19) of the 24 guidelines did not include contributions from
key stakeholders such as patients or relatives.
• Only three guidelines considered health-economic effects of the
treatment options or other cost issues (AU, FI, GB1)
• 5 guidelines referred to particular cultural, ethnic or socioeconomic
issues either in diagnostic assessment or treatment planning (AU,
DK, GB1, SG, US1).
• Only 6 guidelines were reviewed externally by reviewers not
involved in the guideline development.
• Only 6 guidelines (AU, DK, FI, GB1, NO, US1) gave background
information and detailed recommendations for specific mental
health community treatment.
40. • Large variations in the type and frequency of psychosocial
interventions recommended.
• A majority of guidelines recommended some kind of family support
or family involvement
• Half had recommendations for psycho-educational interventions
and vocational rehabilitation. However, recommendations
concerning psychosocial interventions were generally not detailed.
41. Indian Psychiatric Society (IPS) guidelines
• Indian Psychiatric Society task force on clinical practice guidelines for
psychiatrists in India proposed clinical practice guidelines for psychiatrists
in India
• Based on the national workshop held at Jaipur in 2004.
• A detailed literature review, mentions elaborate list of the Indian studies
• Include specific recommendations about treatment of the acute,
continuation/stabilization, maintenance/stable phase of various mental
illnesses.
• Include several recommendations about pharmacological management,
group and individual therapy, vocational rehabilitation and specific
psychosocial interventions
• Distinct advantage of being easy to use and comprehend- clearly convey
the duration of treatment and other important issues/ algorithms given at
the end of chapters further simplify the user’s understanding/ a point-
wise listing of the guidelines
Indian J Psychiatry 49(4), Oct-Dec 2007
42. But……
• Influence of Indian studies on the final drafting of the guidelines is not
clear; the guidelines seem to be a direct adaptation of the Western
literature.
• Studies occur separately as a table or in the bibliography, without any
mention in the text.
• Depth of recommendations- lacking strength
• Cost and resource- guideline failed to conceptualize this important aspect
in the IPS guidelines- no mention of the cost of therapy of any of the
illnesses;
• Supposed to serve as guiding principles for the Indian psychiatrists- not
been properly reflected in the drafting of the IPS guidelines.
– Drugs or psychotherapeutic techniques which are not available in India
or are available at very few centers.
– Do not give enough emphasis to the available resources
43. But….
• Timely review/ update not done
• Specificity or ease of operationalizing- almost didactic in format,
making them more difficult to operationalize
• Contributor bias
• Lack a structured format- not uniform
• Ethnicity, psychosocial and cultural considerations- not done
44. Conclusion
• ??Unified guideline
• Scope of vast improvement in Indian scenario
• Guideline dissemination and implementation
• Specific mental health guidelines could be of considerable
importance in changing mental health treatment and
professional performance.
45. References
• Institute of Medicine Committee to Advise the Public Health Service on
Clinical Practice Guidelines. Clinical Practice Guidelines: Directions For A
New Program. Washington DC: National Academy Press, 1990.
• Vlayen J. et al. A systematic review of appraisal tools for clinical practice
guidelines: multiple similarities and one common deficit. International
Journal for Quality in Health Care 2005; Volume 17, Number 3: pp. 235–
242
• http://www.implementationscience.com/content/7/1/61
• Gaebel W et al. Schizophrenia practice guidelines: international survey
and comparison. British Journal Of Psychiatry ( 2 0 0 5 ) , 1 8 7, 2 4 8-2 5 5
• AGREE Collaboration. Development and validation of an international
appraisal instrument for assessing the quality of clinical practice
guidelines: the AGREE project. Qual Saf Health Care 2003; 12: 18–23.
• Goel D, Trivedi JK. Clinical practice guidelines for psychiatrists: Indian
Psychiatric Society guidelines vs. international guidelines: A critical
appraisal. Indian J Psychiatry 49(4), Oct-Dec 2007