Association Clinical Practice Guidelines Research Articles

Abstract 4124585: Identification of Low-Value Carotid Ultrasound Tests: A Comparison of Administrative Claims Versus Chart Review

Introduction/Background: Low-value care is defined as care where harms or costs outweigh patient benefits. Prior studies have suggested that approximately 1 of every 10 carotid ultrasound tests are low-value because they were performed among patients without neurologic symptoms or a history of stroke. However, these studies have used administrative claims data that may not account for all patient symptoms or include all guideline-recommended indications. We assessed the validity of a claims-based measure of low-value carotid ultrasound testing compared to a reference standard of chart review. Hypothesis: Claims-based measures overestimate the proportion of carotid ultrasound tests classified as low-value care. Methods: We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries attributed to an accountable care organization with administrative claims data linked to electronic health record data. Using Current Procedural Technology codes, the first 150 patients that underwent carotid ultrasound in 2021 were identified. We applied a claims-based algorithm used by researchers and policymakers to identify if testing was low-value or appropriate. We used linked electronic health record data to assess appropriateness of testing using the 2012 American Heart Association clinical practice guidelines. We assessed agreement between claims and chart review using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Cohen’s Kappa. Results: Among 150 patients (mean age 76, 55% male, 86% white) who underwent carotid ultrasound, 76 tests (51%) were considered low value by the claims measure and 63 (42%) by chart review. Claims based measures were 67% sensitive, 61% specific, with a PPV of 55% and NPV of 62%. Cohen’s Kappa coefficient was 0.27 (CI 0.11 - 0.42), indicating only fair agreement between claims and chart review. Conclusion: We found that an often-used claims-based measure to identify low-value carotid ultrasound testing misclassifies a substantial proportion of tests as low-value. Using claims-based measures alone for assessing provider quality and making payment decisions could harm provider reputations and erode trust in the quality reporting system.

Description of Medical and Surgical Conditions Requiring Referral by Physical Therapy Providers in Primary Contact Musculoskeletal Practice

OBJECTIVE: The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association's clinical practice guideline recommendations provide a foundation for clinicians' musculoskeletal care. Some patients’ presenting clinical findings suggest conditions that would benefit from medical or surgical evaluation and management. Guidelines are not available that direct this referral. DESIGN: This practice description directs the development of guidelines for clinicians working as first provider musculoskeletal practitioners on the diagnostic criteria for referring clients for medical or surgical management. METHODS: The foundational step in developing these guidelines is to identify the conditions that first provider musculoskeletal practitioners are likely to encounter during clinical practice. This study used standard practice analysis methodology to identify and describe these conditions. RESULTS/CONCLUSION: The ensuing clinical practice guideline, based on systematic methods to evaluate and classify evidence, will provide graded recommendations on the criteria to identify, level of confidence with identifying, and urgency for referring patients, with the conditions described in this practice analysis, for medical and surgical evaluation and management.

Response to Letter to the Editor Regarding "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation" by Cartotto et al.

Response to Letter to the Editor Regarding "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation" by Cartotto et al.

Letter to the Editor Regarding "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation" by Cartotto et al.

Letter to the Editor Regarding "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation" by Cartotto et al.

#1452 Halting the progression of chronic kidney disease; an audit of the use of renin-angiotensin-aldosterone blockers and SGLT-2 inhibitors

Abstract Background and Aims Sodium-glucose cotransporters-2 inhibitors (SGLT2i) were initially developed for the treatment of type 2 diabetes. Multiple studies have demonstrated the renoprotective effect of SGLT2i, with the capacity to slow diabetic kidney disease and non-diabetic proteinuric chronic kidney disease progression. More recently, the EMPA-KIDNEY trial demonstrated a benefit in patients with chronic kidney disease with a wider range of albuminuria and glomerular filtration rate. We aim to identify the proportion of patients on renin-angiotensin aldosterone system blockade (RAASb) such as angiotensin converting enzyme inhibitor (ACEi), and angiotensin II receptor blocker (ARB), and sodium-glucose transporter-2 inhibitor (SGLT2i) in our Nephrology outpatients clinic. We also aim to encourage awareness and prescribing of RAASb and SGLT2i in eligible patients with CKD. Method A prospective audit was performed in Galway University Hospital (GUH) from September 2023 to October 2023. The audit questionnaire was completed by doctors reviewing patients in OPD. The use of ACEi/ARB/SGLT2i was recorded during the consultation. Results 165 patients were included in the audit with a mean (±SD) age of 62.1 ± 18.6 years. The 3 most common primary renal diagnoses were diabetic kidney disease; 20/165 (12.1%), hypertensive renal disease; 18/165 (10.9%) and IgA nephropathy; 15/165 (9.1%). The mean estimated glomerular filtration rate (eGFR) was 46.8 ± 24.5 ml/min/1.73 m². At baseline, 94/165 (57%) were already on RAASb, none on dual RAASb agents. 20/165 (12.1%) were already on SGLT2i, amongst these, 15/20 (75%) were also on RAASb at the time of the OPD consultation. 13/165 (7.9%) patients were maximised on RAASb and 4/165 (2.4%) commenced an SGLT2i at the clinic visit. Guideline directed medical therapy according to the EMPA-Kidney and UK Kidney Association Clinical Practice Guidelines would suggest missed opportunity on therapeutic optimisation with RAASb and SGLT2i in 66/83 (79.5%) patients; 26/66 (39.4%) were neither on RAASb or SGLT2i, 34/66 (51.5%) were on RAASb but not on SGLT2i, 3/66 (4.5%) were on SGLT2i but not on RAASb, and 3/66 (4.5%) were on sub-maximal RAASb with an SGLT2i. Conclusion There is new evidence to support the use of SGLT2i, in those with chronic kidney disease with a wide range of albuminuria. SGLT2i use is underutilised in our clinic. Ideally, these patients should be initiated on an SGLT2i after being established on a RAASb early in their diagnosis to ensure the optimal renoprotective effects of SGLT2i.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation.

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023.

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

Evolution of Value in American College of Cardiology/American Heart Association Clinical Practice Guidelines.

In January 2014, the American College of Cardiology/American Heart Association released a policy statement arguing for the inclusion of cost-effectiveness analysis (CEA) and value assessments in clinical practice guidelines. It is unclear whether subsequent guidelines changed how they incorporated such concepts. We analyzed guidelines of cardiovascular disease subconditions with a guideline released before and after 2014. We counted the words (total and per page) for 8 selected value- or CEA-related terms and compared counts and rates of terms per page in the guidelines before and after 2014. We counted the number of recommendations with at least 1 reference to a CEA or a CEA-related article to compare the ratios of such recommendations to all recommendations before and after 2014. We looked for the inclusion of the value assessment system recommended by the writing committee of the American College of Cardiology/American Heart Association policy statement of 2014. We analyzed 20 guidelines of 10 different cardiovascular disease subconditions. Seven of the 10 cardiovascular disease subconditions had guidelines with a greater term per page rate after 2014 than before 2014. Across all 20 guidelines, the proportion of recommendations with at least 1 reference to a CEA changed from 0.44% to 1.99% (P<0.01). The proportion of recommendations with at least 1 reference to a CEA-related article changed from 1.02% to 3.34% (P<0.01). Only 3 guidelines used a value assessment system. The proportion of recommendations with at least 1 reference to a CEA or CEA-related article was low before and after 2014 for most of the subconditions, however, with substantial variation in this finding across the guidelines included in our analysis. There is a need to organize existing CEA information better and produce more policy-relevant CEAs so guideline writers can more easily make recommendations that incentivize high-value care and caution against using low-value care.

2023 Clinical Practice Guidelines for Diabetes: Management of Cardiovascular Risk Factors

To prevent cardiovascular disease (CVD), which is one of the ultimate goals in the management of patients with diabetes, it is important to control not only hyperglycemia, but also modifiable CVD risk factors such as hypertension and dyslipidemia. In addition, antiplatelet agents should be used under appropriate conditions. It is necessary to evaluate whether the patient has CVD, the degree of other complications, the presence of comorbidities or other CVD risk factors, and the duration of diabetes. In this article, I will review the revised and key points of the 8th edition of the Korean Diabetes Association clinical practice guidelines for management of hypertension and dyslipidemia and the use of antiplatelet agents in patients with diabetes.

American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite.

This Clinical Practice Guideline addresses severe frostbite treatment. We defined severe frostbite as atmospheric cooling that results in a perfusion deficit to the extremities. We limited our review to adults and excluded cold contact or rapid freeze injuries that resulted in isolated devitalized tissue. After developing population, intervention, comparator, outcomes (PICO) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations based on the available scientific evidence were formulated through consensus of a multidisciplinary committee. We conditionally recommend the use of rapid rewarming in a 38 to 42°C water bath and the use of thrombolytics for fewer amputations and/or a more distal level of amputation. We conditionally recommend the use of "early" administration of thrombolytics (≤12 hours from rewarming) compared to "later" administration of thrombolytics for fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of vascular imaging studies to determine the use of and/or the time to initiate thrombolytic therapy. No recommendation could be formed on the use of intravenous thrombolytics compared to the use of intra-arterial thrombolytics on fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of iloprost resulting in fewer amputations and/or more distal levels of amputation. No recommendation could be formed on the use of diagnostic imaging modalities for surgical planning on fewer amputations, a more distal level of amputation, or earlier timing of amputation.

Evaluation of Financial Conflicts of Interest and Quality of Evidence Underlying the American Diabetes Association Clinical Practice Guidelines: The Standards of Medical Care in Diabetes, 2021.

Clinical practice guidelines make recommendations based on the best available evidence. Proper management and disclosure of financial conflicts of interest (FCOIs) are necessary for trustworthy clinical practice guidelines. This study evaluated the prevalence of FCOIs and quality of evidence underlying the American Diabetes Association (ADA)guidelines. Using the Open Payments Database (OPD) between 2018 and 2020, we examined the research and general payments to all authors of the Standards of Medical Care in Diabetes, 2021. The quality of evidence and tone of recommendations were assessed and the associations between the two were evaluated by logistic regression analysis. Of the 25 guideline authors, 15 (60.0%) were United States (US)-based physicians eligible for the OPD search. Eight (32.0%) and 12 (48.0%) received one or more industry payments one year and three years prior to the guideline publication, respectively. The median total payments (interquartile range) per author were $33,262 ($4,638‒$101,271) in 2020 and $18,053 ($2,529‒$220,659) in 2018-2020. One author received a research payment of over $10,000 undeclared. Of 471 recommendations, 61 (13.0%) and 97 (20.6%) were supported by low-quality evidence and expert opinions, respectively. Also, 439 (93.2%) recommendations had a positive tone. The lower quality of evidence tended to recommend positively with an odds ratio of 1.56 (95% confidence interval: 0.96-2.56, p=0.075) without reaching statistical significance. A minority of the guideline authors received industry payments from the healthcare industry, and declared FCOIs were mostly accurate. However, the ADA FCOI policy required the guideline authors to declare their FCOIs for one year before publication. A more transparent and rigorous FCOI policy is needed in the ADA guidelines.

Cost Analysis for the Management of Acute Coronary Syndrome using Different Quality of Care Indicators

Objective. This study determined the economic burden for nonfatal uncomplicated acute coronary syndrome (ACS) using 100% compliance to certain a) non-invasive or b) invasive and non-invasive diagnostic and therapeutic interventions with class I recommendations in the American College of CardiologyAmerican Heart Association (ACC-AHA) clinical practice guidelines for ACS in three tertiary hospitals using the societal perspective. It also determined the costs using the patient’s perspective in the setting of one private tertiary hospital.&#x0D; Methods. This study was a cost analysis that included a) costs of patient’s resources, b) production losses, and c) costs of other resources or sectors, from hospitalization to one month postdischarge for ACS. Several models were constructed due to variations in the costs of diagnostic and therapeutic interventions in the three settings.&#x0D; Results. Using the societal perspective, one model for noninvasive options yielded the following (costs as of January 31, 2009): hospital A, Php87,014 - 124,799; hospital B, Php75,592 - 96,072; hospital C, Php71,969 - 92,148. Excluding fibrinolytic therapy, the lowest total cost would be Php65,000. However, if coronary angiography was added to the models for hospital C, the cost was Php107,154 - 134,574 (coronary angiography was not available in hospitals A and B). Using the patient’s perspective, theadjusted mean cost for the model which used the least expensive medication was Php96,421 (Standard Deviation = 34,076).&#x0D; Conclusion. The economic burden for nonfatal uncomplicated ACS may range from Php65,000 - 134,574.

EE121 Cost-Effectiveness of Family Based Treatment for Pediatric Obesity: A Literature Review

While Obesity epidemic exerts a vast economic burden with its high medical care cost and comorbidity attribute, managing the growth of obesity among millions of children became a major challenge for the nation’s healthcare. Evidence shows that behavioral therapies are one of the best treatment options for pediatric obesity. American Psychological Association Clinical practice guideline for childhood obesity (March 2018) strongly recommends Family based multicomponent intervention to treat pediatric obesity.

American Speech-Language-Hearing Association Clinical Practice Guideline on Aural Rehabilitation for Adults With Hearing Loss.

Hearing loss poses a significant public health challenge as a common chronic condition with many known side effects that are often worse when left untreated. Aural rehabilitation (AR) is an umbrella term that encompasses a range of interventions (e.g., informational counseling and perceptual training) designed to reduce deficits related to hearing loss that may stand alone or be used in combination as part of a holistic plan. This evidence-based clinical practice guideline is intended to inform the implementation of person-centered AR to adults with hearing loss. Given the well-known benefits of sensory management, it was not included within the scope of this guideline. The recommendations aim to help clinicians, individuals with hearing loss, and other stakeholders make evidence-informed treatment decisions and improve clinical outcomes, as well as provide payers and policymakers with information detailing a comprehensive approach to AR. The American Speech-Language-Hearing Association (ASHA) and a multidisciplinary panel of subject matter experts prioritized key clinical questions and outcomes that served as the foundation of the guideline. The clinical recommendations were based on a comprehensive systematic review and a meta-analysis of 85 studies published between 1978 and 2021. Given the current state of the evidence, resource considerations, patient acceptability, clinical feasibility, and the overall balance of benefits and harms, ASHA developed several evidence-based recommendations for the provision of AR to adults with hearing loss. Each recommendation is accompanied by a series of key practice points to support its implementation within a person-centered framework.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury.

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population. The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI. A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation. This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

Integrating institutional and individual self‐reflexivity practices into clinical pharmacy practice: A critical review of race in a widely utilized medical guideline

AbstractIn this clinical pharmacy forum, an argument is presented that clinical pharmacists and their respective institutions must be self‐reflexive about race, racism, and implicit bias in treating patients. Drawing on the Public Health Critical Race praxis and self‐reflexivity practices, this forum provides a critical review of a widely utilized medical guideline and tool, the American College of Cardiology (ACC) and American Heart Association (AHA) Clinical Practice Guideline on the Primary Prevention of Cardiovascular Disease and its respective Arteriosclerotic Cardiovascular Disease Risk Estimator, as an example of how self‐reflexive practices on race, racism, and implicit bias can be accomplished. This critical review offers clinical pharmacists entry points of considerations and actions that can more robustly aid themselves and their institutions to enact racial justice policies and practices in medical contexts.

CME Exam 1: American Gastroenterological Association Clinical Practice Guidelines on the Pharmacological Management of Irritable Bowel Syndrome with Constipation (IBS-C) and American Gastroenterological Association Clinical Practice Guidelines on the Pharmacological Management of Irritable Bowel Syndrome with Diarrhea (IBS-D)

CME Exam 1: American Gastroenterological Association Clinical Practice Guidelines on the Pharmacological Management of Irritable Bowel Syndrome with Constipation (IBS-C) and American Gastroenterological Association Clinical Practice Guidelines on the Pharmacological Management of Irritable Bowel Syndrome with Diarrhea (IBS-D)

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication

BackgroundThese clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors. MethodsThe Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the “Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014” and “Minds Manual for Clinical Practice Guideline Development 2017.” Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters. ResultsTwenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined. ConclusionWe established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

IJU this Issue

This issue of International Journal of Urology contains one Review Article, 10 Original Articles, and eight editorial comments. Yuan et al. (Jiangsu, China) updated a meta-analysis for the diagnostic performance of the Vesical Imaging–Reporting And Data System (VI-RADS) for predicting muscle-invasive bladder cancer (MIBC) with 20 studies published between September 2018 and July 2021. VI-RADS was introduced in 2018 to define a standardized approach to imaging and reporting multiparametric magnetic resonance imaging for patients with bladder cancer. The diagnostic performance of the VI-RADS for predicting MIBC was excellent in both cutoff points of the VI-RADS 3 and 4. Multiple image acquisition planes of diffusion-weighted imaging should be given more attention in the VI-RADS. We hope that VI-RADS will become more mature and prevalent, which should lead to better management of bladder cancer via further studies. In the original articles, Nishimura et al. (Nara, Japan) evaluated the clinical outcomes and prognostic factors in Japanese patients with bacillus Calmette-Guerin (BCG)-unresponsive nonmuscle-invasive bladder cancer (NMIBC) who underwent early radical cystectomy (RC) using a large-scale multicenter retrospective study and concluded the highest-risk status among the pre-BCG factors was associated with upstaging to extravesical tumors and poor prognosis, despite early RC procedures. The Japanese Urological Association Clinical Practice Guidelines for Bladder Cancer 2019 recommended that patients with BCG-unresponsive disease are considered unlikely to benefit from further BCG therapy and early RC. This study seems to be one of those with the evidence based on a pathological evaluation. Although some new strategies such as intravesical nadofargene firadenovec gene therapy (Lancet Oncol. 2021; 22: 107–17), pembrolizumab monotherapy (Lancet Oncol. 2021; 22: 919–30) have been reported, there is no doubt that BCG-unresponsive disease is a risk factor and RC will continue to be required in a certain proportion of patients with BCG-unresponsive NMIBC. Kato et al. (Osaka, Japan) evaluated the long-term incidence and clinical features of post-transplant lymphoproliferative disorders (PTLD) in kidney transplant recipients from two major transplantation centers in Japan. Graft survival has improved due to a reduction in the acute rejection rate by advances in immunosuppressive agents; however long-term survival after kidney transplantation remains unchanged. Therefore, it is extremely important to focus on malignancy, especially PTLD after kidney transplantation. They emphasized the strategies to identify PTLD and suggested the benefits of positron emission tomography-computed tomography for ascertaining PTLD. They also revealed that mycophenolate mofetil contributed the onset of PTLD, and rituximab was not significantly associated with the incidence of PTLD. We have to be careful for each immunosuppressive agent. Yamashita et al. (Shizuoka, Japan) examined the incidence and location of lower extremity deep vein thrombosis (DVT) in patients undergoing RC. Venous thromboembolism (VTE) including DVT and pulmonary embolism is a serious perioperative complication in urological surgery. RC, whether open or robot-assisted surgery, is the procedure with the highest risk of perioperative VTE in urological surgery according to the European Association of Urology (EAU) guidelines on thromboprophylaxis in urological surgery. They also identified that preoperative D-dimer level was a significant risk factor for preoperative DVT, and preoperative D-dimer level, type of urinary diversion (ileal neobladder), and preoperative DVT were significant risk factors for postoperative DVT. EAU guidelines strongly recommended the use of pharmacological prophylaxis in all patients undergoing open and robot-assisted RC. These results might suggest appropriate patients for pharmacological prophylaxis in RC. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of the International Journal of Urology. None declared.

An Analysis of the Evidence Underpinning the American Urologic Association Clinical Practice Guidelines

ObjectiveTo evaluate the reporting quality of systematic reviews (SRs) underpinning the American Urologic Association (AUA) clinical practice guidelines (CPGs). MethodsWe searched the AUA for CPGs from 2015–2021. We extracted all SRs from the reference sections and two independent investigators evaluated eligible SR/meta-analysis using the PRISMA (Preferred Reporting Instrument for Systematic Reviews and Meta-Analyses) and AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) instruments. We compared SRs conducted by the Cochrane group to non-Cochrane SRs using a Mann-Whitney test. A multivariate regression was used to compare study characteristics. ResultsEighteen CPG's met inclusion criteria. We extracted 120 unique SRs, which accounted for 5.1% (n = 120/2346) of all citations. Mean percent adherence to PRISMA and AMSTAR-2 was 65.4% –d 55.2% respectively. SRs conducted by the Cochrane Collaboration scored higher on AMSTAR-2 compared to non-Cochrane (z = -4.41, P <.01) and a positive correlation between PRISMA and AMSTAR-2 scores (r = 0.56, P <.001) was determined. ConclusionOur study indicated the quality of SRs used to develop AUA CPGs across both PRISMA and AMSTAR-2 was variable. Despite higher evaluations, Cochrane SRs accounted for less than 15% of SRs underpinning CPG recommendations. Given the importance placed on CPGs within clinical practice, we recommended a synergistic relationship between the AUA and the Cochrane Collaboration to increase the number of quality urologic SRs.