High-quality Clinical Practice Guidelines Research Articles

Critical appraisal of Australian and New Zealand paediatric vision screening clinical practice guidelines using the AGREE II tool

ABSTRACT Clinical Relevance Vision disorders in children impact health-related quality of life, with early detection and intervention improving outcomes and educational performance. Eye health professionals should be aware of paediatric vision screening guidelines and their development to understand the components of local programmes and the differences in sensitivity and specificity between protocols. Background High-quality clinical practice guidelines (CPGs) for vision screening enable the early detection of common vision disorders; however, they require rigorous development to ensure optimal accuracy in detecting vision disorders, enabling timely interventions. This study evaluated the quality of available vision screening CPGs on vision screening of children in Australia and New Zealand. Methods A systematic search of academic databases, guideline databases, professional associations and Google search engines was conducted to identify relevant paediatric vision screening CPGs. Four independent reviewers used the Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument to assess the quality of individual guidelines and scores were aggregated and reported as the percentage of the total possible score across the six AGREE II domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence. Results Initial 2,999 items were evaluated, with seven guidelines included. AGREE-II quality score agreement ranged from 43.3% to 95.8%. All guidelines scored >60.0% in the scope and purpose, however, most had poor scores of <26.5% in the rigour of development and <3.3% in editorial independence domains. All guidelines recommended screening using measures of habitual distance vision. Conclusion Of the guidelines developed for use in Australia and New Zealand, most guidelines scored poorly when assessed against the AGREE II tool, because of lack of editorial independence and rigour of development. Paediatric vision screening guidelines should prioritise systematic review of literature to inform practice and include statements regarding competing interests.

Systematic evaluation of Merkel cell carcinoma clinical practice guidelines using the AGREE II instrument

Merkel cell carcinoma (MCC) is a rare type of skin cancer that requires a multidisciplinary approach with a variety of specialists for management and treatment. Clinical practice guidelines (CPGs) have recently been established to standardize management algorithms. The objective of this study was to appraise such CPGs via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Eight CPGs were identified via systematic literature search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Four appraisers trained in AGREE II protocols evaluated each CPG and deemed two CPGs as high quality, five as moderate quality, and one as low quality. Intraclass correlation coefficients (ICCs) were calculated to verify reviewer consistency as excellent, good, and moderate across four, one, and one domain, respectively. The majority of MCC CPGs are lacking in specifying stakeholder involvement, applicability, and rigor of development. The two high quality CPGs are from the Alberta Health Services (AHS) and the collaboration between the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer (EDF/EADO/EORTC). The EDF/EADO/EORTC CPG had the highest overall score with no significant deficiencies across any domain. An important limitation is that the AGREE II instrument is not designed to evaluate the validity of each CPG’s recommendations; conclusions therefore can only be drawn about each CPG’s developmental quality. Future MCC CPGs may benefit from garnering public perspectives, inviting external expert review, and considering available resources and implementation barriers during their developmental stages.

Egyptian Pediatric Guidelines for the Management of Children with Isolated Thrombocytopenia Using the Adapted ADAPTE Methodology-A Limited-Resource Country Perspective.

Thrombocytopenia is a prevalent presentation in childhood with a broad spectrum of etiologies, associated findings, and clinical outcomes. Establishing the cause of thrombocytopenia and its proper management have obvious clinical repercussions but may be challenging. This article provides an adaptation of the high-quality Clinical Practice Guidelines (CPGs) of pediatric thrombocytopenia management to suit Egypt's health care context. The Adapted ADAPTE methodology was used to identify the high-quality CPGs published between 2010 and 2020. An expert panel screened, assessed and reviewed the CPGs and formulated the adapted consensus recommendations based on the best available evidence. The final CPG document provides consensus recommendations and implementation tools on the management of isolated thrombocytopenia in children and adolescents in Egypt. There is a scarcity of evidence to support recommendations for various management protocols. In general, complete clinical assessment, full blood count, and expert analysis of the peripheral blood smear are indicated at initial diagnosis to confirm a bleeding disorder, exclude secondary causes of thrombocytopenia and choose the type of work up required. The International Society of Hemostasis and thrombosis-Bleeding assessment tool (ISTH-SCC BAT) could be used for initial screening of bleeding manifestations. The diagnosis of immune thrombocytopenic purpura (ITP) is based principally on the exclusion of other causes of isolated thrombocytopenia. Future research should report the outcome of this adapted guideline and include cost-analysis evaluations.

GRADE-ADOLOPMENT of hyperthyroidism treatment guidelines for a Pakistani context

IntroductionThe prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of hyperthyroidism in Pakistan.MethodsWe employed the GRADE-ADOLOPMENT approach utilizing the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.ResultsThe source guideline included a total of 124 recommendations, out of which 71 were adopted and 49 were excluded. 4 recommendations were carried forward for adaptation via the ETD process, with modifications being made to 2 of these. The first addressed the need for liver function tests (LFTs) amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs (ATDs). The second pertained to thyroid status testing post-treatment by radioactive iodine (RAI) therapy for Graves’ Disease (GD). Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management.ConclusionOur newly developed hyperthyroidism CPGs for Pakistan contain two context-specific modifications that prioritize patients’ finances during the course of hyperthyroidism management and to limit the overuse of laboratory testing in a resource-constrained setting. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations.

Post-polypectomy surveillance: follow-up recommendations from the Alberta Colorectal Cancer Screening Program

Abstract In 2013, the Alberta Colorectal Cancer Screening Program (ACRCSP) initially published recommendations for post-colonoscopy follow-up and polypectomy. Over time, emerging evidence and evolving surveillance guidelines from various expert groups necessitated a comprehensive review to align with the healthcare landscape in Alberta. To accomplish this, an expert panel was convened. Using the Agree II tool, we identified high-quality Clinical Practice Guidelines that were relevant to the Alberta medical context. Recommendations from these guidelines were adapted to fit the specific needs of Alberta. Recognizing inconsistencies and gaps within the existing guidelines, we conducted targeted literature reviews to ensure a comprehensive and evidence-based approach to our recommendations. Our revised recommendations build upon the assumption that a high-quality index colonoscopy has been performed at baseline. They are intended to enhance the quality of care and reduce unnecessary procedures. As well, they align with the growing consensus in the scientific literature that individuals with low-risk tubular adenomas may not require aggressive colonoscopy surveillance. The updated Alberta recommendations aim to provide clear recommendations for practicing endoscopists, referring physicians, and their patients. They address crucial questions such as determining which patients should commence surveillance via colonoscopy and which individuals should return to average-risk screening using the fecal immunochemical test (FIT). Additionally, our recommendations outline the appropriate surveillance intervals for those requiring continued monitoring.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Japanese physical therapist's evidence-to-practice gap in knee osteoarthritis clinical practice guidelines: A cross-sectional study.

As management for osteoarthritis, clinical practice guidelines (CPGs) have been published worldwide with the aim of attaining optimal treatment and rehabilitation. However, we suspect a lack of knowledge of and/or adherence to osteoarthritis CPGs in physiotherapists' clinical practice. There may be an evidence-to-practice gap in knee osteoarthritis rehabilitation among Japanese physiotherapists. Therefore, we aimed to measure the level of knowledge and adherence to osteoarthritis CPGs within a cohort of Japanese physiotherapists. An online survey was created based on three appropriate and high-quality CPGs. The first two sections comprised 23 statements, and participants responded via a five-point Likert scale ("completely disagree" to "completely agree"). Consensus was defined as ≥70% agreement with a statement. In the second section, participants read clinical scenarios and selected what they considered to be the most appropriate management and interventions. The survey was completed by 558 Japanese physiotherapists. The mean age of the participants included in the analysis was 34.8years, 61 participants were female (13.7%). Consensus was attained in just 12 out of 23 items (52%). In the second section, none of the physiotherapists were considered to have good knowledge of CPGs, 85.2% were considered to have only partial knowledge, and 14.8% had no knowledge. Familiarity with the CPGs was therefore poor and there was clearly poor adherence to the recommended rehabilitation guidelines. The level of knowledge and adherence to osteoarthritis CPGs within our cohort was poor, suggesting an evidence-to-practice gap in rehabilitation for knee osteoarthritis among Japanese physiotherapists.

Critical quality appraisal and algorithm development of clinical practice guidelines for management of poststroke sensory loss: a systematic review

ObjectivesThis study aimed to assess the methodological quality of clinical practice guidelines (CPGs) associated with the management of poststroke sensory loss and develop an algorithm for health professionals.MethodsWe conducted a...

SAT124 GRADE-adolopment Of Adult Diabetes Mellitus Management Guidelines For A Pakistani Context

Abstract Disclosure: A. Pervez: None. R. Martins: None. M. Masood: None. O. Mahmud: None. N. Rizvi: None. A. Sheikh: None. N. Islam: None. A. Khowaja: None. N. Ram: None. S. Furqan: None. M. Mustafa: None. S. Aamdani: None. A. Haider: None. S. Nadeem: None. Background: Pakistan has the highest national prevalence (1 in 4 adults) of type 2 diabetes mellitus (T2DM) in the world. Most T2DM clinical practice guidelines (CPGs) originate from high-income countries and are evidence based. Due to the lack of research infrastructure and financial resources, lower-middle income countries face challenges in the de novo creation of CPGs. Thus, we aimed to develop a comprehensive, high-quality CPG with a local context for adult outpatient T2DM management in Pakistan based on the GRADE-ADOLOPMENT process. Methods: In collaboration with the GRADE working group, an adaptation of the GRADE-ADOLOPMENT approach was followed. Adolopment is a combination of adoption, adaptation, and de novo development. The American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 was utilized as the source CPG by local endocrinology experts in Pakistan. Recommendations from the source CPG were either adopted as is, excluded, or adapted. Adaptation was done using the evidence-to-decision framework with a panel of experts. Results: The source CPG contained 243 recommendations, 219 of which were adopted without change. 5 recommendations were adopted with minor changes related to cost effectiveness to minimize cost-related nonadherence. 18 recommendations were excluded due to reasons including but not limited to the scope being beyond the initial aim of our guideline centers’ objective (such as recommendations related to pediatric or inpatient care), unavailability of medication, or inapplicability to the existing health-care system of Pakistan. One recommendation was adapted pertaining to the screening age for the diagnosis of T2DM. This was recommended to be lowered from the age of 45 years to 30 years due to the higher prevalence of T2DM in younger Pakistanis. This will enable the early detection and management of T2DM. Earlier screening highlights the opportunity to intervene early on and reduce complications. This, coincidentally, was also addressed by the ADA in their 2022 guideline, where the screening age was revised from 45 years to 35 years. Conclusion: Our GRADE-ADOLOPED CPG for T2DM management comprises of 225 recommendations. We recommend earlier screening for T2DM in Pakistan. We additionally suggest careful consideration of cost to promote adherence while also recommending CGM use in the management plan of people with T2DM who can afford it. Our modified methodology provides an excellent resource efficient method to create locally contextualized evidence-based CPGs. Our goal is to publish and disseminate this CPG to improve the quality of T2DM care in Pakistan. Rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan should be conducted in the future. Presentation: Saturday, June 17, 2023

FRI515 GRADE-Adolopment Of Hyperthyroidism Treatment Guidelines For A Pakistani Context

Abstract Disclosure: A. Pervez: None. R. Martins: None. A. Aziz: None. S. Raja: None. N. Islam: None. A. Ahmed: None. A. Sheikh: None. S. Furqan: None. N. Ram: None. A. Rizwan: None. N. Rizvi: None. M. Mustafa: None. S. Aamdani: None. B. Ayub: None. M.Q. Masood: None. A. Haider: None. S. Nadeem: None. Background: Hyperthyroidism is a common endocrinological disorder in Pakistan. The prevalence of hyperthyroidism here is four times higher than the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) originate from high-income countries. Due to resource constraints, de novo local guideline creation is restricted in lower-middle income countries which adopt internationally created CPGs lacking a local context. Thus, we aimed to produce a comprehensive evidence-based CPG for the management of adult outpatient hyperthyroidism patients in Pakistan. Methods: An adaptation of the GRADE-ADOLOPMENT process was followed in collaboration with the GRADE working group. Adolopment describes a combination of adoption (verbatim use), adaptation (contextual modifications), and de novo development, thus leveraging the benefits of pre-existing high-quality CPGs while ensuring local appropriateness. The 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis was selected as the source CPG by a panel of local endocrinology experts. Recommendations from the source CPG were either adopted, excluded, or adapted. Adaptation was done using the evidence-to-decision framework. Results: The source CPG included a total of 124 recommendations, of which 71 were adopted as is. 49 recommendations were excluded due to reasons including but not limited to unavailability of drugs, inapplicability to the existing health-care system of Pakistan or different target audience. 4 recommendations were carried forward for adaptation, 2 of these remained unchanged after collection of local contextual data and consensus between the local endocrinologists. 2 recommendations were modified from the source CPG. The first recommended using ALT only instead of a full liver function test amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs. The second pertained to thyroid status testing post-treatment by radioactive iodine therapy for Graves’ Disease with only FT4 instead of a full thyroid profile. Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management. Conclusion: Our CPG for the management of hyperthyroidism in Pakistan consists of 75 recommendations, of which two recommendations have context-specific adaptations that prioritize patients’ finances during hyperthyroidism management and limit the overuse of laboratory testing in a resource-constrained setting. Our revised methodology is a resource-efficient method for developing CPGs with a local context. We aim to publish and disseminate this CPG to improve hyperthyroidism care provision in Pakistan. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations. Presentation: Friday, June 16, 2023

Improving the quality of clinical practice guidelines in China: A call to action for editors of medical journals

High-quality clinical practice guidelines (CPGs) have the potential to standardize medical practice and improve patient outcomes. However, in China, the quality of CPGs is generally lower than the global average, particularly in terms of methodological and reporting quality. This hinders the dissemination and implementation of CPGs in healthcare practice. To enhance the scientific rigor and authority of CPGs, their development should adhere to reporting guidelines. As medical journals serve as the platform for CPG publication, editors of medical journals have a significant responsibility for the quality control of publishing CPGs. We call on editors of medical journals to be equipped with the CPG reporting guidelines, implement them in their journal practice, and actively participate in the development of CPGs. Additionally, editors of medical journals can also promote CPG quality awareness among medical professionals and journal editors. These efforts will contribute to the high-quality development of CPGs in China.

Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process

IntroductionOlder adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length...

Quality and Content Concordance of International Clinical Guidelines on Hypertensive Disorders of Pregnancy Using the AGREE II Instrument: An Updated Systematic Review.

Utilization of high-quality clinical practice guidelines has the potential to positively impact health outcomes. This study aimed to assess the quality and content concordance of national and international recommendations on hypertensive disorders of pregnancy (HDPs). Searches were conducted of the MEDLINE database and reference lists generated from national and international agencies. Covidence software was used for the management of the systematic review process, the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess guidelines for quality, and three reviewers independently screened records. The research team identified and screened a total of 399 records of which 10 were deemed high quality. Guidelines were assessed and compared regarding the treatment, prevention, and categorization of disorders. The quality of guidelines varied across different domains, with significant variation in domain scores even within individual guidelines. Not all recommendations showed a high level of methodologic rigor, and the highest-rated guidelines were from the American Heart Association, the World Health Organization, and South Africa national guidelines. Classification of hypertension differed among the guidelines, particularly in defining chronic hypertension, severe hypertension, and preeclampsia. Prevention modalities varied across guidelines, with recommendations for aspirin, calcium supplementation, and against the use of certain approaches. Treatment modalities highlighted the importance of delivery as the definitive way to terminate hypertensive disorders of pregnancy, with other management strategies provided for symptom control. The variability in guidelines and consensus statements across different contexts may reflect regional differences in healthcare practices, available resources, and research evidence. There is potential to harmonize guidelines for HDP globally while considering the unique needs of individual countries. Where guidelines may be synthesized and condensed into an accessible format, doing so could improve their use in clinical decision-making.

Cannabis use among cancer survivors in 22 states: Results from the Behavioral Risk Factor Surveillance System, 2020.

This study identified factors associated with recent cannabis use and cannabis use for medical purposes among cancer survivors relative to individuals without a history of cancer. Data from the Behavioral Risk Factor Surveillance System were analyzed for the 22 states completing the optional cannabis module in 2020. Weighted multiple logistic regression was performed to explore variables associated with past 30-day cannabis use and cannabis use for medical purposes, stratified by history of cancer. Covariates included state-level cannabis policy, sociodemographic characteristics, health status indicators, and substance use. Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (7.57% vs. 10.83%). However, a higher proportion of cancer survivors reported use for medical purposes (82.23% vs. 62.58%). After adjusting for state-level policy, biological sex, age, educational attainment, self-reported race/ethnicity, home ownership, mental health status and physical health status, current smoking (odds ratio [OR], 5.14 vs. 3.74) and binge drinking (OR, 2.71 vs. 2.69) were associated with cannabis use in both groups. Characteristics associated with medical cannabis use varied for the two groups; however, daily use (20-30days; OR, 1.72 vs. 2.43) was associated with cannabis use for medical purposes in both groups after adjusting for other variables in the model. A high proportion of individuals report cannabis use for medical purposes with higher rates among cancer survivors. Findings support the urgent need for ongoing cannabis research to better understand and inform its use for medical purposes, as well as the development of high-quality standardized education materials and clinical practice guidelines.

Methodological rigor and reporting quality of clinical practice guidelines for adults hospitalized with bacterial pneumonia: a scoping review protocol.

This scoping review presents a profile of methodological rigor and reporting quality of clinical practice guidelines for adults hospitalized with bacterial pneumonia. An ideal clinical practice guideline is evidence-based and the product of a rigorous and robust literature-vetted process, yet reports show that rigor is not being achieved. Moreover, a new vulnerable population has been identified due to COVID-19. Preliminary searches yielded no scoping or systematic reviews on methodological rigor and reporting quality of clinical practice guidelines used for managing bacterial pneumonia in hospitalized adults. This review will consider current national and international clinical practice guidelines for management of hospitalized adult patients with either suspected or confirmed primary bacterial pneumonia. The review will include adult patients with multiple diagnoses if there is a clearly delineated clinical practice guideline for pneumonia. A 3-step search strategy will be conducted using JBI methodology for scoping reviews. After an initial MEDLINE search for keywords, a broad search of 7 databases, 1 simultaneous platform, gray literature, specialty organizations, and international guideline groups will be conducted from 2017 to present, in any language. Reference lists will be screened for additional sources. A 2-step screening process will be used to identify eligible clinical practice guidelines. Three reviewers will independently extract data, using a standardized form. Domain scores will be analyzed and presented as percentages, and the results will be interpreted as map trends. https://osf.io/h896x.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. Level II-therapeutic study.

Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges.

Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan. We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context. The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan. A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.

A Systematic Review of Clinical Practice Guidelines for Managing Pulmonary Toxicities Caused by Immune Checkpoint Inhibitors: Quality of Treatment Recommendations and Differences in Management Strategies Between Guidelines.

Pulmonary toxicities caused by immune checkpoint inhibitors are a prominent concern for clinicians. Clinical Practice Guidelines (CPGs) are critical for managing these toxicities. A systematic search of CPGs on checkpoint-associated pulmonary toxicities (ca-PT) was conducted in October 2022. PubMed, Embase, Cochrane Library, CINAHL, and Web of Science were searched. AGREE II and AGREE-REX were used to appraise CPGs and recommendations quality, respectively. Descriptive statistics, intraclass correlation coefficient, Kruskal-Wallis (H) test, and Spearman's correlation were used for analyses. P-values < .05 were considered statistically significant. Matrices were used to determine recommendation differences between CPGs. The study's design was based on the PRISMA 2020 checklist for systematic reviews. Protocol registration number: CRD42022358435. Eight CPGs (two high-quality, three moderate-quality, and three low-quality) were identified. All CPGs covered pneumonitis. One CPG covered pleural effusions and pneumonitis/SARs-CoV-2-infection. Three CPGs covered sarcoidosis-like-reactions. CPGs for pulmonary fibrosis, airway disease, bronchiolitis, and diffuse alveolar damage, were unavailable. No CPG recommendation was based on a prospective study, and none were appraised as high-quality. Also, recommendations were not specific to histopathologic subtypes. AGREE II's "rigor of development," the domain that evaluates a guideline's methodological approach and strategies in gathering scientific evidence, correlated strongly with AGREE-REX's "overall quality" pneumonitis recommendations, r = .952; P < .01. Approximately 73% of recommendations on pneumonitis were similar between high-quality CPGs. About 16% to 74% of low-quality CPGs were similar to those recommended by high-quality CPGs. Prospectively designed research projects focusing on all types of ca-PT and their histopathologic subtypes are urgently needed. Due to the lack of high-quality recommendations in available CPGs, the disparities in treatment recommendations between high-quality CPGs, and the similarities in recommendations that exists between high-quality and low-quality CPGs, clinicians should thoroughly assess and responsibly appraise all available CPG recommendations in formulating treatment strategies for ca-PT.

A comprehensive systematic review of colorectal cancer screening clinical practices guidelines and consensus statements.

High-quality clinical practice guidelines (CPGs) and consensus statements (CSs) are essential for evidence-based medicine. The purpose of this systematic review was to appraise the quality and reporting of colorectal cancer (CRC) screening CPGs and CSs. After prospective registration (Prospero no: CRD42021286156), a systematic review searched CRC guidances in duplicate without language restrictions in ten databases, 20 society websites, and grey literature from 2018 to 2021. We appraised quality with AGREE II (% of maximum score) and reporting with RIGHT (% of total 35 items) tools. Twenty-four CPGs and 5 CSs were analysed. The median overall quality and reporting were 54.0% (IQR 45.7-75.0) and 42.0% (IQR 31.4-68.6). The applicability had low quality (AGREE II score <50%) in 83% of guidances (24/29). Recommendations and conflict of interest were low-reported (RIGHT score <50%) in 62% guidances (18/29) and 69% (20/29). CPGs that deployed systematic reviews had better quality and reporting than CSs (AGREE: 68.5% vs. 35.5%; p = 0.001; RIGHT: 74.6% vs. 41.4%; p = 0.001). In summary, CRC screening CPGs and CSs achieved low quality and reporting. It is necessary a revision and an improvement of the current guidances. Their development should apply a robust methodology using proper guideline development tools to obtain high-quality evidence-based documents.

A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol

BackgroundUp to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients.MethodsWe will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation – Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations.DiscussionThis review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients.Trial registrationThis study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6.