Clinical Practice Guidelines Research Articles

‘How-To:’ Scoping Review?

Scoping reviews are a type of evidence synthesis that aims to identify and map the breadth of evidence available on a particular topic, field, concept, or issue, within or across a defined context or contexts. Scoping reviews can contribute to clinical practice guideline development, policy making, reduce research waste by eliminating duplication of research effort, and be a precursor to a systematic review. This paper aims to provide a brief introduction of how to conduct and report scoping reviews, their role and value of within the evidence synthesis ecosystem, the differences and similarities between these reviews and other types of evidence syntheses such as systematic reviews, mapping reviews, evidence and gap maps and overviews and how to overcome common challenges often associated in the conduct, reporting and dissemination of scoping reviews.

JS3-2 Evidence gaps in cardio-oncology clinical practice guidelines – a sea of opportunity

JS3-2 Evidence gaps in cardio-oncology clinical practice guidelines – a sea of opportunity

Quality Improvement Initiative: Identifying Barriers to Reducing Time to First Feed With Human Milk in Low Birth Weight Infants.

Early exposure to human milk and time to first trophic feed in low birth weight (LBW) infants (<2 kg) is associated with a decreased risk of mortality, sepsis, and length of hospital stay. This project, focused on infants born at less than 2 kg, aimed to identify the mean time to first feed after birth, identify barriers to initiation of the first feed, and meet the target of having 90% of infants receive their first feed within the first 6 hours of life. This quality improvement (QI) project occurred in a thirty-bed level III NICU over 29 months using two Plan-Do-Study-Act (PDSA) cycles. A first-feed audit tool and a multifaceted educational plan were at the forefront of this initiative. Interventions were multidisciplinary, targeted, and extended to all healthcare team members caring for LBW infants, including staff of Labor and Delivery, the NICU, and the Child Health Transport Team. At the end of the QI project, 91.3% of inborn infants and 27.5% of outborn infants were being fed by 6 hours of age, compared with 78.8% and 12.5%, respectively, prior to the project. The mean time to first feed for inborn infants after the PDSA cycles was reduced to 4.4 hours, having a decrease of 80 minutes. A multidisciplinary approach was a key factor in the success of this QI initiative. Increasing staff education and improving clinical practice guidelines regarding the importance of early exposure to human milk are associated with reducing first feed times after birth.

Predicting mucosal inflammation in IBD patients using patient-reported symptom scores and a faecal calprotectin home test: protocol for a multicentre prospective validation study

IntroductionCrohn’s disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD) with a relapsing-remitting nature. With adequate non-invasive prediction of mucosal inflammation, endoscopies can be prevented and treatment optimised earlier...

Variable practice patterns in the surgical management of renal hyperparathyroidism

BackgroundHyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The American Association for Endocrine Surgery published clinical practice guidelines that address the surgical treatment of secondary and tertiary hyperparathyroidism. The purpose of this study is to determine practice patterns for the surgical management of secondary and tertiary hyperparathyroidism prior to guideline publication. MethodsWith the approval of the American Association for Endocrine Surgery, a Qualtrics email survey was sent to the Association’s membership in 2022 about current clinical decision making for surgical treatment of secondary and tertiary hyperparathyroidism. Respondents were divided into groups based on surgical subspecialty (endocrine surgery versus non-endocrine surgery), yearly parathyroidectomy volume, and yearly parathyroidectomy volume for surgical treatment of secondary and tertiary hyperparathyroidism. Descriptive statistics were performed; the role of volume was evaluated. ResultsThere were 142 responses from 795 solicited email addresses (18% response rate); 114 (84%) identified as endocrine surgeons. The majority (62%) perform >50 parathyroidectomies yearly, but most perform <10 parathyroidectomies for surgical treatment of secondary and tertiary hyperparathyroidism per year (<10/y, 53.7%; 10–30/y, 41.9%; >30/y, 4.4%). Subtotal parathyroidectomy is most commonly performed for surgical treatment of secondary (83%) and tertiary (52%) hyperparathyroidism, but transcervical thymectomy variably performed for both. There was no consensus regarding starting calcitriol preoperatively (always 43%, never 25%, depends on vitamin D levels 24%) or stopping cinacalcet (2 weeks prior 28%, day of surgery 29%, postoperatively 20%). Surgeons who perform >10 parathyroidectomies per year for surgical treatment of secondary and tertiary hyperparathyroidism were less likely to consider the patient's preoperative vitamin D levels to inform their decision to start calcitriol before surgery (<10 cases/year, 34%; ≥10 cases/year 15%; P = .023), were more likely to have a postoperative hypocalcemia protocol managed by the surgical team (<10 cases/year, 49%; ≥10 cases/year, 58%; P = .029), and were more likely to use intraoperative parathyroid hormone monitoring for tertiary hyperparathyroidism (<10 cases/year, 70%; ≥10 cases/year, 87%; P = .046). ConclusionThe majority of respondents perform <10 parathyroidectomies yearly for surgical treatment of secondary and tertiary hyperparathyroidism. Subtotal parathyroidectomy was most commonly performed, but there was little other consensus regarding preoperative management, intraoperative decision-making, and postoperative care. Opportunity exists through guideline dissemination to improve heterogeneity of care provided to surgical treatment of secondary and tertiary hyperparathyroidism patients.

P4.17F.05 Adherence to Clinical Practice Guideline - Analysis of 89 Multidisciplinary Team Discussed Patients with Stage III Lung Cancer

P4.17F.05 Adherence to Clinical Practice Guideline - Analysis of 89 Multidisciplinary Team Discussed Patients with Stage III Lung Cancer

Critical Evaluation of the 2016 SOSORT Clinical Guidelines on the Detection and Clinical Management of Adolescent Idiopathic Scoliosis Using the AGREE II Tool: A Chiropractic Perspective

ObjectiveThe objective of this study is to assess the methodological quality of the 2016 Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines for the detection and management of adolescent idiopathic scoliosis. MethodsA diverse group of experts, including practicing chiropractors, chiropractors with a Diplomate by the American Chiropractic Board of Radiology, chiropractors with PhD degrees, and chiropractors involved in teaching within chiropractic programs was invited to participate in the study. Experts independently evaluated the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool. Individual scaled scores were calculated for each item and the 6 domains, with methodological quality considered good if the score was equal to or greater than 70%. ResultsThe 19 experts, including 6 clinicians, 4 chiropractic radiologists, 6 researchers, and 3 lecturers, represented Canada (n = 3), United states (n = 4), France (n = 2), Australia (n = 1), United Kingdom (n = 1), Switzerland (n = 1), Sweden (n = 3), Denmark (n = 2), China (n = 1), and Côte d'Ivoire (n = 1). Domain scaled scores ranged from 38% to 90%. The 4 items of the applicability domain scored between 26% and 45%. The experts made suggestions for improving the applicability of the guidelines’ recommendations. ConclusionThe methodological quality of the 2016 SOSORT clinical practice guidelines was deemed good. However, strategies should be devised to improve their applicability. This could be achieved by involving a more diverse representation of healthcare professions in the development of future guidelines.

SY8-4 The essence of the Clinical Practice Guidelines for the care of psychologically distressed bereaved families and future prospects

SY8-4 The essence of the Clinical Practice Guidelines for the care of psychologically distressed bereaved families and future prospects

Engaging Multi-Disciplinary Teams to Develop Pragmatic Clinical Practice Guidelines to Support Management of Patients with High-Risk Breast Lesions

IntroductionWe sought to develop clinical guidelines within our multidisciplinary Breast Center to support decision-making for managing high-risk breast lesions. The objective is to describe the process used to develop these guidelines and assess perceived acceptability. MethodsWe recruited clinical stakeholders to identify key “high-risk” topics. Stakeholder groups (surgery, radiology, pathology) met separately to review the topics, leveraging existing literature reviews and best available evidence. Guidelines were initially developed in 2015 and updated in 2019. We surveyed breast clinical team members in 2023 regarding the perceived acceptability of the guidelines and summarized the data. ResultsWe created clinical guidelines to address the management of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia/lobular carcinoma in situ, radial scar/complex sclerosing lesion, and papillomas. Key guideline components included process for radiologic-pathologic correlation, patient disposition after biopsy (surgical referral needed, follow-up imaging recommended), recommendation for the role of surgical excision, and recommendation regarding imaging follow-up if excision not performed. Forty clinical team members (66% [40/60] response rate) completed the acceptability survey from varied disciplines. Most (78%) were aware of the guidelines. Respondents rated the recommendations for disposition after biopsy, surgical management, and follow-up imaging as the most helpful components. Most (>80%) rated them to be very/extremely useful. ConclusionWe leveraged input from key stakeholders to develop clinical guidelines to support the multi-disciplinary management of patients with high-risk breast lesions. Our guidelines have been successfully implemented across our academic and community practice. Future steps will assess the impact of implementation on clinical outcomes. Micro abstractWe leveraged input from key stakeholders to develop clinical guidelines to support the multi-disciplinary management of patients with high-risk breast lesions. Key guideline components included process for radiologic-pathologic correlation, patient disposition after biopsy, and recommendation for surgery. Our guidelines were acceptable to stakeholders. Future steps will assess the impact of implementation on clinical outcomes.

O10-4 Current status and future of patient and public involvement in pancreatic cancer clinical practice guidelines revision

O10-4 Current status and future of patient and public involvement in pancreatic cancer clinical practice guidelines revision

Anticoagulation Therapy Timing in patients with Atrial Fibrillation after Acute and Chronic Subdural Haematoma (ATTAACH): a pilot randomised controlled trial

IntroductionSubdural haematomas (SDHs), acute or chronic, are common neurosurgical diagnoses. These problems can occur among patients requiring direct oral anticoagulation (DOAC) for atrial fibrillation. There are currently no guidelines regarding...

Acute Lymphoblastic Leukemia, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for acute lymphoblastic leukemia (ALL) provide recommendations for management of ALL, with a focus on the classification of ALL subtypes based on immunophenotype and cytogenetic/molecular markers; risk assessment and stratification for risk-adapted therapy; treatment strategies for Philadelphia chromosome (Ph)-positive and Ph-negative ALL for both adolescent and young adult and adult patients; and supportive care considerations. This selection from the NCCN Guidelines for ALL focuses on treatment recommendations for adults with newly diagnosed Ph-negative ALL based on current evidence.

Prehospital seizure management protocols need standardized guidelines. A descriptive study from Norway.

BackgroundPatients with convulsive seizures constitute a significant group in acute neurology. No common European clinical practice guidelines on prehospital seizure management exists, and today most patients are brought to hospital for seizure treatment, with great variation in which prehospital treatment is provided. Only 33% of status epilepticus patients receive a benzodiazepine as first anti-seizure medication (ASM). The aim of this study is to assess the prehospital seizure control protocols in the Emergency Medical Services (EMS) in Norway, and compare these with current evidence for acute management. MethodWe performed a descriptive analysis of the 18 regional EMS protocols in Norway and compared the findings with recent evidence on prehospital treatment. We analysed recommended drug and dosage, route of medication administration, number of additional rescue doses permitted, requirements for registration of type of seizures and seizure duration. ResultsThe protocols vary in terms of preferred medication, administration method, dosage and recommendations regarding first- and second-line therapies. 33 % of protocols explicitly define status epilepticus according to contemporary guidelines, and 16.7 % have an operational definition of when to administer benzodiazepines. All protocols showed variations in dosing and administration instructions and only 28% had a clearly stated first line treatment. ConclusionThere are disparities in the prehospital seizure management protocols within the Norwegian healthcare system, a system comparable to other European countries. To improve seizure management there is a need for standardised guidelines for prehospital treatment.

Prescribing of pancreatic enzyme therapy for malabsorption in unresectable pancreatic cancer: Cross-sectional survey across New Zealand and Australia

ObjectiveTo investigate the practices of clinicians prescribing pancreatic enzyme replacement therapy (PERT) for unresectable pancreatic cancer in Aotearoa New Zealand and Australia. MethodsA mixed media advertising campaign was used to recruit appropriate clinicians to complete a questionnaire that collected demographic data, information regarding prescribed medication, and awareness of PERT guidelines. ResultsThe study recruited 161 clinicians, with 93 and 68 respondents from Aotearoa New Zealand and Australia respectively. Most respondents from both countries were experienced gastrointestinal surgeons and dietitians. Aotearoa New Zealand clinicians and dietitians used faecal elastase more frequently to diagnose PEI than other groups. Clinicians had a tendency to under-prescribe PERT, and to advise incorrectly on the timing of the medication. The majority of clinicians from Aotearoa New Zealand and Australia were not aware of any best practice clinical guidelines for PERT (70 % and 77 %, respectively). ConclusionThis study suggests clinicians are over-reliant on faecal elastase to diagnose PEI and are uncertain about the correct dose and timing of PERT for optimal patient benefit in those with unresectable pancreatic cancer. Most clinicians were not aware of best practice guidelines.

Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting: Technical Report.

This technical report summarizes the results of a systematic review designed to support the American Academy of Pediatrics' "Clinical Practice Guideline: Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." PubMed and Excerpta Medica Database were searched from 2010 to 2023 to identify randomized clinical trials and systematic reviews related to outpatient opioid prescribing to children. Overall, 11 randomized controlled trials were included. Although data were limited, no evidence was found that pain control by opioids is superior to nonopioid alternatives. Further, opioids are often associated with adverse events. The review also suggests that family and patient education and providing disposal methods may decrease risks associated with opioid prescription. Future studies can build on this foundation of evidence to support the appropriate use of opioids for acute pain in children treated in the outpatient setting.

Higher oxidative balance score is linearly associated with reduced prevalence of chronic kidney disease in individuals with metabolic syndrome: evidence from NHANES 1999-2018.

Oxidative stress is a key contributor to the development of chronic kidney disease (CKD) in individuals with metabolic syndrome (MetS). The oxidative balance score (OBS) is an emerging composite assessment tool for dietary and lifestyle oxidative balance. We aimed to explore the association of OBS with CKD prevalence in MetS in this national cross-sectional analysis. This was a national cross-sectional analysis. Eligible MetS participants ≥20 years of age from NHANES 1999-2018 were included. OBS was assessed according to previous well-validated methods and consisted of 16 dietary components and 4 lifestyle components. MetS was diagnosed by NCEP-ATP III criteria, while CKD was diagnosed by KDIGO 2021 Clinical Practice Guideline. Multivariate logistic regression models were used to explore the association of OBS with CKD in MetS in this national cross-sectional analysis. A total of 8,095 MetS participants were included, with a CKD prevalence of 24.8%. In fully adjusted models, each score increases in OBS, dietary OBS, and lifestyle OBS was associated with a 2, 1.7, and 7.3% reduction in the prevalence of CKD, respectively. Higher OBS, dietary OBS, and lifestyle OBS were all associated with significantly lower odds of CKD (p for trend all <0.05). Restricted cubic spline analysis showed that these associations all exhibited inverse dose-response. Interaction analyses indicated that cardiovascular disease (CVD) status significantly influenced the impact of OBS and dietary OBS, and these associations were only present in CVD-free subjects. Defining MetS using the IDF criteria did not significantly change the results. OBS was inversely associated with the prevalence of CKD in MetS, especially in CVD-free settings. These findings emphasize that adherence to an antioxidant diet and lifestyle contributes to the early prevention of CKD in the MetS population and necessitates attention to CVD interactions. Future prospective cohort studies are needed to confirm these results.

Knowledge, Attitudes, and Practices of Filipino Medical Interns on the Management of Superficial Cutaneous Mycoses: A Cross-sectional Study.

Superficial mycoses are one of the most common skin conditions encountered in the outpatient clinics, causing significant morbidity amongst patients. Since these are highly prevalent diseases of the skin, the general practitioner should be able to manage uncomplicated cases, with no need for evaluation by a specialist. The study aimed to determine the knowledge, attitudes, and practices of Filipino medical interns on the management of superficial cutaneous mycoses using a self-administered questionnaire. This may help identify possible gaps in knowledge, as well as obstacles these future clinicians may encounter when managing superficial mycoses. This in turn may assist in the development or improvement of dermatology training among medical students and continuing medical education programs amongst non-dermatologist physicians. This is a descriptive cross-sectional study among medical interns of the Philippine General Hospital to investigate their knowledge, attitudes, and practices regarding the management of superficial mycoses. Eligible participants were asked to complete an online self-administered survey questionnaire which assessed their capacity to recognize and manage uncomplicated superficial mycoses, and determined their attitudes regarding dermatology training in medical school. The study included 170 medical interns, with majority having only 1-4 weeks of cumulative duration of dermatology training in medical school. Many of the participants (67.1%) had inadequate overall knowledge scores, but this was not significantly associated with their cumulative duration of dermatology training, as well as with their frequency of encounters with superficial mycosis patients. Most deem dermatology training (92.4%) and learning about the management of superficial mycoses (91.2%) during medical school very important. Majority are interested in attending more courses or training in the subject. Recommendations to improve medical school training on superficial mycoses include more practical approach in dermatology modules, integration of dermatology electives in medical school, and longer duration of dermatology modules/rotations during medical school. While knowledge scores of medical interns were not significantly associated with the duration of their dermatology training during medical school as well as their encounters with patients with superficial mycoses, it is shown that they have low confidence scores regarding management of superficial mycoses. They deem that learning more about this disease and dermatology in general is vital to their medical education and are desirous of more training in this subject. Recommendations to improve medical school training on superficial mycoses include dermatology modules, rotations or electives in medical school. Additionally, better training during medical school, and formulation of clinical practice guidelines specific to cutaneous mycoses were recommended to improve healthcare delivery for patients with such diseases.

A Discrete-Choice Experiment Assessing the Patient Preferences and Real-World Experiences of Patients with Migraine in Japan.

Migraine is a debilitating headache disorder with a high prevalence in Japan that imposes significant societal burden. Although the Japanese Clinical Practice Guideline for Headache Disorders 2021 recommends both acute and preventive migraine treatments, the usage of preventive treatments is still limited. Therefore, it is crucial to understand the treatment preferences of patients with migraine pertaining to both acute and preventive treatments. A mixed-methods study including a discrete choice experiment (DCE) was conducted with Japanese patients with migraine (10 for the qualitative interviews, and 400 for the DCE) who were recruited from the Rakuten Insight panel. The DCE presented hypothetical treatment options including oral acute, oral preventive, and injectable preventive medications. Six attributes (method of delivery, reduction of pain, impact of headaches on daily routines, dosage adjustability, and temporary and persistent side effects) each with three levels were included in the survey. A hierarchical Bayesian model was used to estimate relative attribute importance scores (RAI) for all attributes. For the 400 participants in the DCE, the most common age bracket was 40-49years old, and the majority were female (66.75%). RAI estimates indicated that "method of delivery" was the most important attribute for patients (RAI 51.92, SD = 10.20), followed by "reduction of pain when experiencing a headache" (RAI 17.00, SD = 7.74). Oral preventive treatments were preferred over injectable preventive treatments. The qualitative interviews showed that patients prefer oral medications to injectable treatments, and a lack of awareness regarding preventive treatments. This study found that the "method of delivery" was the most important driver of treatment preferences of patients with migraine in Japan, with oral acute medications being preferred. Oral preventive treatments were found to be preferred over injectable treatments. These results may indicate the need for increased education regarding preventive treatments, as well as the need for further development of these treatments.

Efficacy and safety of dexamethasone sparing for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents: a systematic review and meta-analysis of the Clinical Practice Guidelines for Antiemesis 2023 from the Japan Society of Clinical Oncology.

Chemotherapy-induced nausea and vomiting (CINV) are common side effects, classified according to timing and severity. Conventional agents such as dexamethasone are effective but have various side effects. For moderately emetogenic chemotherapy, dexamethasone-sparing antiemetic therapies have been developed to minimize these side effects. This systematic review evaluated the efficacy and safety of dexamethasone-sparing antiemetic therapy for highly emetogenic chemotherapy (HEC). We performed a thorough literature search for studies related to dexamethasone-sparing antiemetic therapy with neurokinin-1 antagonists (NK1RA) for HEC using the PubMed, Cochrane Library, and Ichushi-Web databases. A qualitative analysis of the combined data was performed and risk differences with confidence intervals were calculated. Two reviewers independently assessed the 425 records and 12 full-text articles were evaluated for eligibility. Two studies were included in the qualitative and meta-analyses. These studies included anthracycline-cyclophosphamide (AC) regimens and cisplatin-based regimens, with palonosetron as the serotonin receptor antagonist. In the two studies, no difference was found in the prevention of vomiting (delayed complete response). However, non-inferiority was not demonstrated in the subgroup that received cisplatin-containing regimens. Delayed complete control showed different results for nausea prevention; however, there was no significant difference in the meta-analysis. Only one report has shown non-inferiority for delayed total control. Although the strength of evidence for individual outcomes varied, there was no difference in the duration of dexamethasone administration. This systematic review and meta-analysis revealed that dexamethasone-sparing antiemetic therapy with NK1RA and palonosetron can be used to prevent CINV in HEC, limited to AC combination therapy.

Atrial fibrillation in combination with severe mitral regurgitation : Which should be treated first, the atrial fibrillation or the mitral valve?

The primary therapeutic approach for severe secondary mitral regurgitation (MR) in combination with atrial fibrillation is often not clear. To create atherapeutic guideline for daily clinical practice based on acase report as well as basic literature. If afunctional component is suspected, restoration of sinus rhythm may lead to asignificant improvement in MR. The extent of the improvement and the time required to achieve this improvement are often difficult to predict. The involvement of an electrophysiologist is recommended in order to assess the likelihood of successful long-term rhythm control aimed at improving MR. In unclear cases, cardioversion combined with short-term administration of antiarrhythmic medication may be useful to demonstrate potential improvement of MR in sinus rhythm.