Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Management of acute bronchiolitis: can evidence based guidelines alter clinical practice?

BACKGROUND: Acute bronchiolitis is the most common lower respiratory tract infection in infants and there is no evidence that drug treatment alters its natural course. Despite this, most Swiss paediatricians reported in 2001 prescribing bronchodilators and inhaled corticosteroids (ICS). This situation led to the creation of national guidelines followed by a tailored implementation programme. The aim of this study was to examine if treatment practices changed after the implementation of the new guidelines. METHODS: A questionnaire on treatment of bronchiolitis was sent to all Swiss paediatricians before (2001) and after (2006) creation and implementation of national guidelines (2003-2005). Guidelines were created in collaboration with all paediatric pulmonologists and implemented carefully using a multifaceted approach. RESULTS: Questionnaires were returned by 541 paediatricians (58%) in 2001 and by 639 (54%) in 2006. While both surveys showed a wide variation in the treatment of bronchiolitis between physicians, reported drug prescription decreased significantly between the two surveys. For outpatients, general use (for all patients) of bronchodilators dropped from 60% to 23%, and general use of ICS from 34% to 6%. For inpatients, general use of bronchodilators and ICS dropped from 55% to 18% and from 26% to 6%, respectively (all p<0.001). The decrease was evident in all regions, among hospital and primary care physicians, and among general paediatricians and paediatric pulmonologists. CONCLUSIONS: National guidelines together with a tailored implementation programme can have a major impact on medical management practices in a country.

Implementation of Evidence-Based Practices for Treatment of Alcohol and Drug Disorders: The Role of the State Authority

The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.

Beyond the Pro and Contra of Evidence-Based Practice: Reflections on a Recurring Dilemma at the Core of Social Work

Currently, social work is witnessing a quite polarized debate about what should be the basis for good practice. Simply stated, the different attempts to define the required basis for effective and accountable interventions in social work practice can be grouped in two paradigmatic positions, which seem to be in strong opposition to each other. On the one hand the highly influential evidence based practice movement highlights the necessity to base practice interventions on proven effectiveness from empirical research. Despite some variations, such as between narrow conceptions of evidence based practice (see e.g. McNeece/Thyer, 2004) and broader approaches to it (see e.g. Gambrill, 1999, 2001, 2008), the evidence based practice movement embodies a positivist orientation and more explicitly scientific aspirations of social work by using positivistic empirical strategies. Critics of the evidence based practice movement argue that its narrow epistemological assumptions are not appropriate for the understanding of social phenomena and that evidence based guidelines to practice are insufficient to deal with the extremely complex activities social work practice requires in different and always somewhat unique practice situations (Webb, 2001; Gray & Mc Donald, 2006; Otto, Polutta &Ziegler, 2009). Furthermore critics of evidence based practice argue that it privileges an uncritical and a-political positivism which seems highly problematic in the current climate of welfare state reforms, in which the question ‘what works’ is highly politicized and the legitimacy of professional social work practice is being challenged maybe more than ever before (Kessl, 2009). Both opponents and proponents of evidence based practice argue on the epistemological, the methodological and the ethical level to sustain their point of view and raise fundamental questions about the real nature of social work practice, so that one could get the impression that social work is really at the crossroads between two very different conceptions of social work practice and its further professional development (Stepney, 2009). However, this article is not going to merely rehearse the pro and contra of different positions that are being invoked in the debate about evidence based practice. Instead it aims to go further by identifying the dilemmas underlying these positions which - so it is argued – re-emerge in the debate about evidence based practice, but which are older than this debate. They concern the fundamental ambivalence modern professionalization processes in social work were subjected to from their very beginnings.

EU Copyright Law, Lobbying and Transparency of Policy-Making: The cases of sound recordings term extension and orphan works provisions

The objective of this paper is to discuss EU lobbying in the area of copyright. Legislation needs to regulate the legal position of various different stakeholders in a balanced manner. However, a number of EU copyright provisions brought into effect over recent years were highly controversial and have led to suggestions that powerful lobbying forces may have had some influence. This article investigates the effects of lobbying on copyright law-making in Europe. A specific comparative and multi-faceted analysis is provided of the legislative process for two recently adopted directives: 2011/77/EU which extends the term of protection of sound recordings and 2012/28/EU which introduces certain permitted uses of orphan works (some references are also made to the ACTA case). Firstly, a short presentation is given of the legal bases for the EU consultation process and lobbying. Next, an analysis is provided of the two cases, taking into consideration the policy-making procedures (with special focus on how the consultation process was handled), the legal solutions proposed and adopted and the various stakeholders’ claims. Lastly, it asks why some interest groups were successful and some others failed (the analysis identifies two types of factor for the effectiveness of lobbying: those resulting from stakeholders’ actions and those connected with the consultation process).

Labor participation in corporate policy-making decisions: West Germany's experience with codetermination

If workers are wealth maximizers, codetermination should lead to less risky investments, smaller dividends, reduced firm leverage, higher and more stable salaries, and more capital-intensive production processes. Unless codetermination also increases productivity by raising wokers' morale and satisfaction or reduces information asymmetries within the firm, shareholder wealth and firm value will decline. An analysis of West Germany's case, however, indicates that codetermination has little, if any, effect on corporate operations and performance.

Evidence based check-up: the general medical point of view

Check-up is a frequent motivation for patients to see their general practitioner. The challenge lies in the choice of screening tools to accomplish an efficient, individual and age-adapted approach. In this article we review evidence-based screening methods, whose efficacy has been demonstrated by randomized clinical trials, as well as their application in clinical practice. While cardiovascular check-up has a high grade of evidence for nearly all patients, counselling to lifestyle change except for smoking cessation has been proved with lower evidence. In contrast, relatively new is the fact that ultrasound to screen for an abdominal aortic aneurysm is useful among men smokers or past smokers between 65 and 75 years old.