AGREE II: advancing guideline development, reporting and evaluation in health care

Systematic review, methodological appraisal, and recommendation mapping of clinical practice guidelines for managing patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

PURPOSE

The Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II) was developed to enhance the methodological rigor of clinical practice guidelines (CPGs), aiming to generate trustworthy recommendations for various clinical scenarios. Despite its importance, there exists a gap in the quality of CPGs pertaining to Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN). The aim of the study was to evaluate SJS-TEN CPGs to shed light on areas for enhancing SJS-TEN guidelines' quality.

MATERIALS AND METHODS

A systematic review was conducted to identify SJS-TEN CPGs from January 2011 to December 2023 across bibliographic and guideline databases, as well as dermatology association websites. Four reviewers employed the AGREE II instrument to appraise the quality of eligible CPGs. Subsequently, AGREE II domain scores were calculated and their recommendations mapped.

RESULTS AND CONCLUSIONS

Seven eligible SJS-TEN CPGs reviewed, originating from Europe, North America, Asia, and an authorship Group. The highest AGREE II domain scores were observed in scope and purpose (mean: 63%, standard deviation [SD]: 23.195%) and clarity of presentation (mean: 70%, SD: 14.5%). Conversely, the lowest score was noted in the applicability domain (mean: 28%, SD: 17.44%). Only two guidelines by the British Association of Dermatologists (28.6%) met the 'recommend' level. Recommendations from all CPGs were compared in tabular form.

Best evidence for rehabilitation management of urinary incontinence in patients with bladder cancer following orthotopic neobladder reconstruction

Objective

This study aims to establish the best evidence for the rehabilitation management of urinary incontinence (UI) in patients with orthotopic neobladder (ONB) following radical cystectomy (RC) for bladder cancer, providing a theoretical foundation for clinical practice.

Methods

A systematic search was conducted across evidence-based databases, guideline networks, and professional association websites to identify relevant literature on rehabilitation management for patients with ONB after bladder cancer surgery. Studies published in both English and Chinese, up to May 8, 2024, were included. Trained researchers assessed the quality of the literature and summarized the evidence.

Results

Fourteen documents were included, consisting of eight guidelines, two clinical decision documents, and four expert consensus reports. A total of 43 pieces of evidence were identified, covering seven key areas: preoperative UI assessment and counseling, preventive measures, UI assessment and diagnosis, conservative treatments, selection and use of nursing equipment, evaluation of effectiveness, and follow-up care.

Conclusions

The best evidence for UI rehabilitation management after ONB for bladder cancer can help standardize patient care and clinical practices. Healthcare providers should adapt this evidence to their local healthcare settings, cultural contexts, barriers, and patient preferences.

Systematic review registration

This study was conducted following the evidence summary reporting specifications of the Fudan University Center for Evidence-Based Nursing (Registration No. ES20244165).

Evidence summary on pain management in thoracoscopic lung cancer surgery

Objective

The study aimed to systematically retrieve, evaluate and summarize evidence on perioperative pain management in adults undergoing thoracoscopic lung cancer surgery, to assist oncology nurses in improving pain assessment and management.

Methods

The research question was established using PIPOST model and a systematic search was conducted in English and Chinese databases, professional society websites and guideline platforms for literature published between January 2017 and December 2024. Included literature types comprised guidelines, systematic reviews, evidence summaries, expert consensus, and standards. After literature searching and screening in January 2025, the remaining guidelines were evaluated by four investigators, while other literature was assessed by two investigators. Evidence was then extracted and graded.

Results

Eighteen articles were included, comprising 5 systematic reviews, 3 guidelines, 2 clinical decisions, 4 evidence summaries, 3 expert consensus, and 1 standard. Twenty-five pieces of evidence across six topics were summarized, covering organizational management, high-risk patient assessment and preoperative education, pain assessment, intraoperative analgesia, multimodal pharmacological strategies, and non-pharmacological interventions.

Conclusions

This evidence summary highlights effective strategies for perioperative pain management in thoracoscopic lung cancer surgery, which could support oncology nurses in implementing comprehensive pain assessment, identifying high-risk patients, and applying diversified analgesic interventions.

Best practice guidelines and service provision for supporting women with birth-related trauma: A scoping review of international literature

PROBLEM

Birth trauma (BT) is a significant public health concern affecting approximately one-third of the 140 million annual births worldwide, yet it lacks a unified approach for effective intervention. This study investigates the global landscape of BT management, focusing on the current best practice guidelines and service provisions for supporting women with birth-related trauma and the practicable actionable gaps that needs to be addressed.

METHODS

This scoping review followed the PRISMA Extension for Scoping Reviews guidelines, and systematically searched 13 electronic databases and websites for clinical guidelines, policy documents, care standards, practice recommendations and service provisions related to BT. The search yielded eight guidelines, of which were assessed using the AGREE II appraisal tool. Additionally, eight peer-reviewed articles focusing on current practices and service recommendations were analysed alongside the guidelines using a narrative synthesis approach.

FINDINGS

There are gaps between guideline recommendations and service experiences, barriers and facilitators at the patient, provider, and system levels as well as between research, policy and clinical practice. Of the guidelines included, only three rated high quality (>70 %).

DISCUSSION

There was consistency in recommending trauma-informed care, collaborative care between health professionals, patient and practitioner education and debriefing as an intervention. However, there were inconsistencies in the definition of BT and most lacked details on the steps, structure or practical tools that should be used. Seven key themes were identified regarding gaps between proposed guidelines and actual experiences of women after traumatic birth.

CONCLUSION

There is an urgent need for standardised, evidence-based guidelines that are user-friendly and provide practical advice for implementing trauma-informed care.

Imaging of peritoneal metastases of ovarian and colorectal cancer: joint recommendations of ESGAR, ESUR, PSOGI, and EANM

OBJECTIVES

Diagnostic imaging of peritoneal metastases in ovarian and colorectal cancer remains pivotal in selecting the most appropriate treatment and balancing clinical benefit with treatment-related morbidity and mortality. To address the challenges related to diagnostic imaging and detecting and reporting peritoneal metastatic spread, a joint guideline was created by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Society of Urogenital Radiology (ESUR), Peritoneal Surface Oncology Group International (PSOGI), and European Association of Nuclear Medicine (EANM).

METHODS

A targeted literature search was performed and consensus recommendations were proposed using Delphi questionnaires and a five-point Likert scale.

RESULTS

A total of three Delphi rounds were performed. Consensus was reached on the position of diagnostic imaging for assessment of operability, treatment response monitoring, and follow-up of peritoneal metastases, optimal imaging modality and their technical imaging requirements depending on the indication and how to optimise communication of imaging results by the report and multidisciplinary board discussion. The complete list of recommendations is provided.

CONCLUSION

These expert consensus statements aim to guide appropriate indications, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients.

KEY POINTS

Question Staging peritoneal metastases (PM) helps to guide clinical decision-making for colorectal and ovarian cancer patients. How can we optimise the use of imaging techniques to assess PM? Findings Imaging plays a crucial role in the detection, operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in colorectal and ovarian cancer patients. Clinical relevance These expert consensus statements aim to guide appropriate indication, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients.

Healthy ageing in older adults with cardiovascular disease

As life expectancy continues to increase due to advancements in medical technology, public health, nutrition, and socioeconomic progress, the population of older adults in the USA and Europe is rapidly growing. By 2050, individuals aged 65 and older are projected to constitute over 20% of the US population and 29% of the European population, leading to a higher prevalence of chronic diseases, including cardiovascular disease. Cardiovascular disease, the leading cause of death in the USA, poses significant challenges to healthy ageing by contributing to accelerated biological ageing and the development of geriatric syndromes. This state-of-the-art review aims to (i) define healthy ageing for older patients living with cardiovascular disease; (ii) compare chronological vs biological ageing as it pertains to cardiovascular disease; (iii) describe the impact of geriatric syndromes and provide an approach to management and prevention; and (iv) address the gaps in knowledge and future directions for potential interventions that could promote healthy ageing.

High-precision information retrieval for rapid clinical guideline updates

Delays in translating new medical evidence into clinical practice hinder patient access to the best available treatments. Our data reveals an average delay of nine years from the initiation of human research to its adoption in clinical guidelines, with 1.7-3.0 years lost between trial publication and guideline updates. A substantial part of these delays stems from slow, manual processes in updating clinical guidelines, which rely on time-intensive evidence synthesis workflows. The Next Generation Evidence (NGE) system addresses this challenge by harnessing state-of-the-art biomedical Natural Language Processing (NLP) methods. This novel system integrates diverse evidence sources, such as clinical trial reports and digital guidelines, enabling automated, data-driven analyses of the time it takes for research findings to inform clinical practice. Moreover, the NGE system provides precision-focused literature search filters tailored specifically for guideline maintenance. In benchmarking against two German oncology guidelines, these filters demonstrate exceptional precision in identifying pivotal publications for guideline updates.

Consensus Clinical Management Guideline for PLA2G6-Associated Neurodegeneration (PLAN)

This clinical guideline provides recommendations for the evaluation and management of individuals with PLA2G6-associated neurodegeneration (PLAN). PLAN, a neurodegeneration with brain iron accumulation disorder, presents with infantile-onset (infantile neuroaxonal dystrophy), juvenile-onset, and adult-onset forms with motor, cognitive, ophthalmologic, and autonomic symptoms. This guideline was developed using a modified Delphi process with input from PLAN experts and family members of individuals with PLAN. A literature search was performed, although in the absence of data, recommendations were based on expert opinion. The guideline contains recommendations on diagnostic approach, disease-specific treatment, and symptom-based management.

Consensus recommendations on multiple sclerosis management in Australia and New Zealand: part 1

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system. There were 33 335 people with MS in Australia in 2021 and 2917 in New Zealand in 2006 and the prevalence and incidence are increasing with time. Although new treatments have substantially improved outcomes in recent decades, the treatment landscape has become increasingly complex due to the expanding number of disease-modifying therapies (DMTs) and associated safety considerations.

MAIN RECOMMENDATIONS

A total of 80 consensus recommendations were developed on the current best-practice management of MS in Australia and New Zealand. Part 1 of these guidelines outlines the consensus recommendations covering domains including DMT counselling and selection, pre-DMT assessments, monitoring disease activity on DMT, switching DMT, and discontinuing DMT. The remaining recommendations are outlined in Part 2, encompassing risk mitigation strategies during treatment with DMT, managing DMT in special situations (including pregnancy, postpartum, breastfeeding, active infection including COVID-19, and malignancy), general lifestyle measures, acute MS relapses, and symptomatic treatments for MS.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES

This two-part position statement provides a practical resource for clinicians on current best-practice consensus recommendations for managing adults (≥ 18 years old) with MS in the Australian and New Zealand health care settings. It outlines the 14 DMTs currently available through the Australian Pharmaceutical Benefits Scheme and eight through the New Zealand Pharmaceutical Schedule, including the unique efficacy, safety and monitoring considerations of each. Through these guidelines, we aim to support safe, timely and effective management of patients with MS in Australia and New Zealand.

Clinical practice guidelines for perioperative multimodality treatment of non-small cell lung cancer

BACKGROUND

Lung cancer is currently the most prevalent malignancy and the leading cause of cancer deaths worldwide. Although the early stage non-small cell lung cancer (NSCLC) presents a relatively good prognosis, a considerable number of lung cancer cases are still detected and diagnosed at locally advanced or late stages. Surgical treatment combined with perioperative multimodality treatment is the mainstay of treatment for locally advanced NSCLC and has been shown to improve patient survival. Following the standard methods of neoadjuvant therapy, perioperative management, postoperative adjuvant therapy, and other therapeutic strategies are important for improving patients' prognosis and quality of life. However, controversies remain over the perioperative management of NSCLC and presently consensus and standardized guidelines are lacking for addressing critical clinical issues in multimodality treatment.

METHODS

The working group consisted of 91 multidisciplinary experts from thoracic surgery, medical oncology, radiotherapy, epidemiology, and psychology. This guideline was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The clinical questions were collected and selected based on preliminary open-ended questionnaires and subsequent discussions during the Guideline Working Group meetings. PubMed, Web of Science, Cochrane Library, Scopus, and China National Knowledge Infrastructure (CNKI) were searched for available evidence. The GRADE system was used to evaluate the quality of evidence and grade the strengths of recommendations. Finally, the recommendations were developed through a structured consensus-building process.

RESULTS

The Guideline Development Group initially collected a total of 62 important clinical questions. After a series of consensus-building conferences, 24 clinical questions were identified and corresponding recommendation were ultimately developed, focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assement, and follow-up protocols for NSCLC.

CONCLUSIONS

This guideline puts forward reasonable recommendations focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assessment, and follow-up protocol of NSCLC. It standardizes perioperative multimodality treatment and provides guidance for clinical practice among thoracic surgeons, medical oncologists, and radiotherapists, aiming to reduce postoperative recurrence, improve patient survival, accelerate recovery, and minimize postoperative complications such as atelectasis.

Seizure prediction in pregnant women with epilepsy: An umbrella review of clinical practice guidelines and systematic reviews

OBJECTIVE

To identify risk factors for seizure in pregnant women, and in the general population with epilepsy.

STUDY DESIGN

Umbrella review of clinical practice guidelines and systematic reviews on risk factors or prediction models for seizure occurrence in pregnant women with epilepsy, adults with epilepsy, or all individuals with epilepsy. Guidelines or systematic reviews exclusively for children were excluded. We searched MEDLINE, Emcare, Embase, CINAHL, TRIP PRO, Epistemonikos, World Health Organisation, Guideline International Network, DANS, and grey literature (2000-2023) without language restrictions. Risk factors or predictors listed in the final guidelines or systematic reviews were collated and thematically analysed.

RESULTS

From 3406 citations, we included 13 articles (ten guidelines, three systematic reviews) reporting 26 risk factors in pregnant women and the general adult population with epilepsy: eight factors in guidelines for pregnant women only; five in both pregnant women and general adult populations (four in both guidelines and systematic reviews, one in guidelines only); and 13 factors in the general adult population (four in both guidelines and systematic reviews, eight in guidelines, and one in a systematic review). Risk factors were categorised into five broad themes: seizure type; seizure control; anti-seizure medication; neurological; and epilepsy and medical history. Three risk factors for seizure ocurrence were cited in more than two guidelines or systematic reviews: seizure freedom (reduced risk), immediate initiation of anti-seizure medication after first seizure (reduced risk), and abnormal electroencephalogram (increased risk). Three risk factors were linked to a more than two-fold chance of seizures in pregnant women with epilepsy: tonic-clonic seizures in the last three months (RR 7.20, 95% CI 6.63-11.93), a history of non-tonic-clonic seizures (RR 2.11, 95% CI 1.88-2.62), and seizures in the pre-pregnancy year compared to no seizures (RR 3.51, 95% CI 3.13-3.94).

CONCLUSION

Multiple risk factors have been recommended for use in practice across different guidelines and reviews to identify those at increased risk of seizures in the adult population with epilepsy, and specifically in pregnant women with epilepsy. Further research is needed on the implementation of tools for predicting seizures to improve maternal and neonatal outcomes.

Korea, Japan, Europe, and the United States: Why are guidelines for gastric cancer different?

As a global health concern, gastric cancer management has been systematized by individual countries and regions into regimented guidelines. To explore international differences, we examined the guidelines of Korea, Japan, Europe, and the United States. Guidelines are created by experts in the field, focusing on evidence-based recommendations to standardize and improve patient care, but the methodology for guideline creation, incorporation of new innovations, and review differs significantly. National and regional differences within the guidelines are apparent, stemming from various factors including local incidence, stage, presentation, patient preferences, and governmental influences. Differences include the use of neoadjuvant chemotherapy, criteria for endoscopic resection, and extent of lymphadenectomy. Nonetheless, fundamental treatment principles remain universal, and the goals of national guidelines are uniform: standardizing patient care, providing the highest quality treatments, incorporating cutting-edge clinical trial results, and consensus in guidelines to help formulate governmental policies. This review highlights how the guidelines are constructed, the unique elements of each guideline, how they differ, and why they differ.

Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.

Best Practices for Chronic Pancreatitis Pain Management: A Comprehensive Evidence-Based Review

Purpose

This study aimed to identify and synthesize high-quality evidence regarding pain management in individuals with chronic pancreatitis (CP) to serve as a reference for clinical practice interventions.

Methods

A thorough review encompassing databases, clinical guidelines, and information platforms, such as UpToDate, Guidelines International Network (GIN), National Institute for Health and Clinical Excellence (NICE), guide.medlive.cn, PubMed, Embase, Chinese Biomedical Literature Service System, China National Knowledge Infrastructure (CNKI), and Wanfang Data, was conducted to gather relevant evidence on pain management in CP. The search encompassed clinical decisions, evidence summaries, guidelines, systematic reviews, and expert consensus documents published up to October 2023. Two researchers independently evaluated included articles and extracted data pertinent to clinical practice.

Results

In total, 21 articles met the inclusion criteria for final analysis, comprising four guidelines, two expert consensus documents, one clinical decision, and 14 systematic reviews. The evidence was categorized into seven key treatment domains: pain evaluation, drug intervention, endoscopic treatment, surgical intervention, Traditional Chinese Medicine (TCM) therapies, other treatment modalities, and approaches tailored to specific populations. 19 individual recommendations were derived from these categories.

Conclusion

This review consolidates the best available evidence for pain management in CP. However, in clinical application, the optimal intervention should be individualized, taking into account patient preferences, the healthcare institution's technical capabilities, and other relevant factors. This approach is crucial for optimizing pain management and enhancing the quality of life in individuals with CP.

Psychotherapies for adults with complex presentations of PTSD: a clinical guideline and five systematic reviews with meta-analyses

OBJECTIVE

To develop a clinician-guided, research-based guideline for adult outpatient psychotherapy for complex presentations of post-traumatic stress disorder (PTSD).

METHODS

We used state-of-the-art methods to develop clinical guideline recommendations and conduct systematic reviews with meta-analyses for five research questions: (Q1) When treating adults with PTSD, should trauma-focused psychotherapy include exposure? Which psychotherapies are effective for PTSD with co-occurring: (Q2) personality disorder; (Q3) depression; and (Q4) dissociative disorder? (Q5) for complex PTSD (C-PTSD)?

RESULTS

(Q1) We found no evidence of a difference between trauma-focused psychotherapies with or without exposure on PTSD symptoms (standardised mean difference (SMD) 0.02, 95% CI -0.11 to 0.15, p=0.75, I2=64%). (Q2) Dialectical behaviour therapy (DBT-for-PTSD) showed beneficial effects over cognitive processing therapy (CPT) on co-occurring borderline personality disorder (BPD) symptoms (mean difference (MD) -0.58, 95% CI -0.94 to -0.22, p=0.003). (Q3) Mindfulness and body-focused psychotherapies, prolonged exposure (PE), narrative exposure therapy (NET) and CPT showed beneficial effects on symptoms of PTSD and co-occurring depression. Results for present-centred therapy (PCT) were uncertain. (Q4) No statistically significant differences were found among psychotherapies for PTSD with co-occurring dissociation. (Q5) Skills training appeared promising for C-PTSD.

CONCLUSION

Weak clinical recommendations were reached for trauma-focused therapies with or without exposure for PTSD; DBT-for-PTSD for PTSD with co-occurring BPD; CPT, NET, PE and Mindfulness and body-focused psychotherapies for PTSD with co-occurring depression; and Skills training for C-PTSD. A weak recommendation was reached against PCT for PTSD with co-occurring depression. It is good practice to include interventions targeting dissociation for PTSD with co-occurring dissociation. Overall, the certainty of evidence was low; high-quality trials are needed to strengthen the recommendations.

PROSPERO REGISTRATION NUMBER

CRD42022376117.

Best evidence summary for preventing and preventing epidermal growth factor receptor inhibitors induced paronychia in cancer patients

Objective

To evaluate and summarize the best evidence for preventing and managing epidermal growth factor receptor inhibitors induced paronychia in cancer patients. It aims to provide a reference for medical staff.

Methods

We systematically searched for evidence on paronychia symptoms in 14 databases such as Cnki、Wanfang, 7 guide websites such as GIN and NZGG, and 8 professional websites such as UICC and ACS from database establishment to August 2024. Two researchers evaluated the quality of the literature and extracted the data.

Results

A total of 20 articles were included in this study, including 5 clinical decisions、5 guidelines、3 evidence summaries 、3 recommended practices, and 4 experts consensuses. Finally, 12 pieces of evidence were summarized from 4 aspects, including risk factor assessment, professional healthcare training, preventive measures, and therapeutic measures.

Conclusion

Our research summarizes the best evidence for preventing and managing epidermal growth factor receptor inhibitors induced by paronychia in cancer patients. In the actual clinical application, it is necessary to fully consider the clinical situation, combine the judgment of professionals and patients' wishes, follow the principle of individualization, analyze the obstacles and facilitating factors of the application of evidence, and apply the evidence to the clinical practice prudently.

The efficacy of gluteal tendinopathy treatments: A systematic review

ObjectiveTo guide clinical practice by synthesising robust evidence concerning gluteal tendinopathy management.Data sourcesFive electronic databases were searched from inception to August 2024 for randomised controlled trials (RCTs) of medium or high quality, and low risk of bias, that measured pain and function in adults with clinically diagnosed gluteal tendinopathy.Review methodsSystematic review reporting proof of efficacy. PEDro scale and Cochrane Risk of Bias Tool 2.0 were used to assess internal validity and risk of bias. Efficacy was determined by comparison to minimal intervention. Methodological heterogeneity prevented meta-analysis, but we calculated standardised mean differences (SMD) and 95% confidence intervals (95% CI) for individual study arms to facilitate comparison between interventions.ResultsFour interventions from four RCTs demonstrated efficacy. Exercise and education has moderate strength evidence of a medium effect on pain (SMD = 0.95; 95% CI [0.58, 1.33]) and function (SMD = 0.91; 95% CI [0.53, 1.28]) in the short term with small effects in the medium and long term. Corticosteroid injection has moderate strength evidence of a small effect on pain (SMD = 0.51; 95% CI [0.16, 0.86]) in the short term. Platelet-rich plasma injection was superior in the short term compared to corticosteroid injection for function (SMD = 0.46; 95% CI [0.00, 0.91]). For pain, focused shockwave therapy (f-ESWT) demonstrates superiority in the long term (SMD = 5.77; 95% CI [4.84, 6.71]) compared to corticosteroid injection.ConclusionsExercise and education can be cautiously recommended as the core approach for pain management and function, potentially supplemented by corticosteroid or f-ESWT, while definitive trials of promising interventions are needed to derive robust practice recommendations.

Interventions for Reducing Mental Health-Related Stigma in Emergency Medicine: An Integrative Review

INTRODUCTION

The prevalence and impact of mental health disorders are increasing worldwide. A growing number of people with mental health problems require ambulance and emergency department care, many of whom face stigmatization from health care professionals in these environments. Interpersonal stigma comprises insufficient knowledge (ignorance or misinformation), negative attitudes (negative emotional reactions, such as prejudice), and negative behaviors (such as avoidance or rejection).

METHODS

An integrative review was conducted to assess the current landscape of interventions aimed at reducing stigmatization among health care professionals in ambulance and emergency department settings.

RESULTS

Of the 18 publications included, 1 targeted stigma reduction. Although 2 additional studies examined interventions not specifically aimed at reducing stigma, these studies have examined the impact of interventions on stigma. The other included studies reported measures of attitudes. One study involved patients evaluating the intervention, whereas the rest relied on assessments by health care professionals. Four studies mentioned patient involvement in the development of interventions. The predominant approach in these studies involved educational and training interventions associated with improvements in knowledge levels and attitudes. However, the direct impact of these changes on reducing stigmatizing behavior remains unclear. It is concerning that national practice guidelines in ambulance and emergency care hardly address mental health-related stigma despite longstanding awareness of this issue.

DISCUSSION

The findings underscore the urgent need for concerted efforts in practice, research, and policy within ambulance and emergency department settings to address and combat stigmatizing behaviors toward patients with mental health challenges by enhancing knowledge and reshaping attitudes.

How do we leverage implementation science to support and accelerate uptake of clinical practice guidelines in transfusion medicine

BACKGROUND

Developing and disseminating clinical practice guidelines is a common strategy used to inform practice and address evidence-to-practice gaps that are prominent in transfusion medicine. Despite a highly systematic method for synthesizing evidence into guideline recommendations, comparatively little attention is paid to the real-world implementation of the recommendations in routine practice. A more scientific approach drawing on learnings from the field of implementation science is therefore warranted.

STUDY DESIGN AND METHODS

In this article, we propose a methodological roadmap to embed implementation science principles, frameworks, and methods to facilitate the development and uptake of transfusion medicine guidelines. We draw upon research undertaken in partnership with the International Collaboration of Transfusion Medicine Guidelines (ICTMG) to illustrate the roadmap in action.

RESULTS

The methodological roadmap constitutes five steps which have been matched to existing processes for developing and implementing clinical practice guidelines: (1) environmental scan; (2) detailing who needs to do what differently, per guideline recommendation; (3) barriers and enablers assessment; (4) tailoring implementation strategies to identified barriers and enablers; and (5) implementation and evaluation of implementation strategies. For each step, we define the key concepts and methods involved, and share examples from work done with ICTMG to support transfusion medicine guideline implementation.

DISCUSSION

We intend this methodological roadmap for clinicians, researchers, and organizations involved in supporting clinical practice guideline use. Informed by principles, frameworks, and methods from implementation science, the roadmap can provide a more structured, transparent, and replicable approach to improve the implementation of guideline recommendations in transfusion medicine.

Bereavement support guidelines for caregivers in palliative care: a scoping review

Background

Palliative care teams' support practices for bereavement vary substantially. Clinical guidelines are needed to promote concerted, evidence-based intervention. The goal of the present study is to identify and synthesize the principles and clinical guidelines that ensure best practices in bereavement support for family caregivers accompanied in palliative care.

Methods

A scoping review was conducted based on a systematic search of articles in academic databases (EBSCO, PsycINFO, PubMed, Web of Science, Psychology and Behavioral Sciences Collection, Scopus) and Google (2010-2024). The review included articles focused on the principles, guidelines, and clinical recommendations for bereavement support for adult family caregivers in palliative care. Quality appraisal of guidelines was conducted using the AGREE II instrument.

Results

Of the 1,489 references identified, 20 documents were included, mostly governmental or institutional norms and clinical guidelines from gray literature. Quality appraisal revealed gaps in evidence selection, resource implications, updates and monitoring criteria. Eight fundamental principles were identified, from which several clinical guidelines were derived, organized according to the moments of assessment and intervention throughout the bereavement process, including pre and post-death period: (1) organizing support for the family caregiver; (2) assessing needs and establishing a care plan; (3) ensuring information and support for the family caregiver; (4) preparing for death; (5) support at the time of death; and (6) bereavement support post-death. In addition to universal support and information measures, regular assessment procedures should be adopted for timely referrals based on individual needs.

Discussion

These guidelines cover the temporal variation of care and the multidimensional and multiple-actor nature of palliative care. Implementing these guidelines and evaluating their impact will allow for the standardization of best practices and improve the quality of bereavement support in palliative care.

Pre-Participation Evaluation of Recreational and Competitive Athletes - A Systematic Review of Guidelines and Consensus Statements

BACKGROUND

Pre-participation evaluation (PPE) aims to support safe participation in sports. The goal of this systematic review was to aggregate evidence- and consensus-based recommendations for the PPE of recreational or competitive athletes as preparation for developing a German guideline on this subject.

METHODS

Five databases, including MEDLINE, were searched in August 2022, complemented by searches on the websites of relevant guideline organisations and specialty medical associations and citation screening. We included guidelines/consensus statements with recommendations for PPE of adult recreational athletes or competitive athletes of any age, excluding those with certain chronic illnesses. We extracted and synthesised data in a structured manner and appraised quality using selected domains of the AGREE-II tool.

RESULTS

From the 6611 records found, we included 35 documents. Overall, the quality of the included documents was low. Seven documents (20%) made recommendations on the entire PPE process, while the remainder focussed on cardiovascular screening (16/35, 45.7%) or other topics. We extracted 305 recommendations. Of these, 11.8% (36/305) applied to recreational athletes and 88.2% (269/305) applied to athletes in organised or competitive sports. A total of 12.8% (39/305) of recommendations were directly linked to evidence from primary studies.

CONCLUSION

Many recommendations exist for PPE, but only a few are evidence based. The lack of primary studies evaluating the effects of screening on health outcomes may have led to this lack of evidence-based guidelines and contributed to poor rigour in guideline development. Future guidelines/consensus statements require a more robust evidence base, and reporting should improve.

REGISTRATION

PROSPERO CRD42022355112.

Risk assessment and management of chemical hazards for pregnant workers: a qualitative review of guidance from EU member states

BACKGROUND

Exposure to workplace chemicals can pose serious risks to reproductive health. The European Union's Pregnant Workers Directive requires risk assessments but lacks clear guidelines for assessing chemical reproductive hazards in workplaces.

AIMS

This study aims to review how EU member states implement the Pregnant Workers Directive by analysing national guidance documents and relevant literature.

METHODS

A qualitative review was conducted, combining a systematic literature search with outreach to EU national experts to gather relevant guidance documents. Thematic synthesis identified guiding principles for implementing maternity protection for chemical exposures.

RESULTS

Two main themes were identified: the need for a broad perspective and for certainty in risk assessment. The broad perspective stresses the importance of considering all reproductive hazards, not limited to those listed in the EU Directive and inclusion of male workers and the preconception period, and the potential adverse socio-economic consequences of applied protective measures. The need for certainty highlights the challenges in reliable risk assessments, due to lack of knowledge about chemicals' hazardous properties, dose-response relationships and the level of worker exposure. These themes reveal the complexity of implementing effective maternity protection and the need for improved guidelines across the EU.

CONCLUSIONS

This study calls for a unified approach to reproductive health protection, extending beyond pregnancy to include also preconception and paternal exposures. The findings highlight the need to support practitioners in the risk assess process at workplaces in the EU by providing a framework for the assessment of reproductive hazards and determining protective measures.

Standardised operating procedures for recommendations in the field of physical and rehabilitation medicine

BACKGROUND

There is an outstanding increased demand for recommendations in the rehabilitation field. Over 600 recommendation articles have been published in the last decade, primarily by groups of authors based on unclear criteria and only a few by learned societies based on standardized methods.

OBJECTIVES

In 2007, the French Society of Physical and Rehabilitation Medicine (SOFMER) published a methodology to establish recommendations in physical and rehabilitation medicine (PRM). This framework, which served to publish 22 sets of management recommendations, must be reworked to meet new international methods for elaborating recommendations. Therefore, our objectives were: 1) to elaborate an updated methodology to enhance the dissemination and implementation of SOFMER-endorsed recommendations, and 2) to standardize and report in sufficient detail the successive steps from the elaboration of these recommendations to the evaluation of their impact and provide supporting tools to guide developers.

METHODS

At the SOFMER's request, a steering committee assembled, consisting of 7 PRM senior physicians with experience in elaborating, disseminating, implementing and/or evaluating recommendations in the field of PRM. They conducted a non-systematic literature review to identify methodologies and standardized operating procedures previously published by scientific societies in France and overseas. Available information regarding strategies for elaboration, dissemination, implementation and evaluation of the recommendations, scientific valorization and business models was retrieved. Participants in previous recommendations were also interviewed regardless of their field.

RESULTS

We identified 4 common key steps: preparation, elaboration, valorization and evaluation, usually scheduled according to an 18- to 24-month timetable. We divided these 4 steps into 9 sub-steps, each of which was standardized and described in detail. The steering committee also elaborated a specific editorial process for publishing recommendations.

CONCLUSIONS

This novel SOFMER methodology was designed to draw up high-level recommendations for the field of PRM and, more generally, for rehabilitation practices, facilitating their implementation. Standardization of operating procedures should provide guidance to authors to achieve replicable and high-quality recommendations.

ERN eUROGEN Guidelines on the Management of Anorectal Malformations Part I: Diagnostics

INTRODUCTION

 Anorectal malformations (ARMs) are rare congenital anomalies that involve the anus, rectum, and oftentimes the genitourinary tract. The management of ARM patients is complex, and many controversies exist. To address this issue, the European Reference Network eUROGEN for rare and complex urogenital conditions aimed to develop comprehensive guidelines for the management of ARM.

METHODS

 The Dutch Quality Standard for ARM served as the basis for the development of guidelines applicable on a European level. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from 7 European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected, and recommendations were formed considering current evidence and/or expert consensus.

RESULTS

 Prenatal and neonatal diagnostic workup as well as postsurgical follow-up of anorectal, genitourinary tract, and neurologic system were reviewed. Seven new studies were identified. The panel adapted 13 recommendations, adopted 7, and developed 8 de novo. The availability of high-quality evidence was limited, and most recommendations were based on retrospective studies, case series, or expert opinion.

CONCLUSION

 Patients with ARM and their families require highly specialized and comprehensive care from the prenatal period to adulthood. This guideline provides recommendations for a comprehensive diagnostic workup of children with ARM throughout their life that is applicable on a European level.

ERN eUROGEN Guidelines on the Management of Anorectal Malformations, Part IV: Organization of Care and Communication between Providers

INTRODUCTION

 Being born with an anorectal malformation (ARM) can have profound and lifelong implications for patients and parents. Organization of care and communication between health care providers is an overlooked area of patient care. The European Reference Network eUROGEN for rare and complex urogenital conditions assembled a panel of experts to address these challenges and develop comprehensive guidelines for the management of ARM.

METHODS

 The Dutch Quality Standard for ARM served as the basis for the development of guidelines. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from seven European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected and recommendations were formed considering all available evidence, expert consensus, and the European context.

RESULTS

 Aspects pertaining to organization of care, patient/parent/health care provider communication, and referral and collaboration between providers caring for ARM patients were assessed. Two new studies were identified. In total, the panel adapted 12 recommendations, adopted 7, and developed 2 de novo. The overall level of newly found evidence was considered low and most recommendations were based on expert opinion.

CONCLUSION

 Collaborative care and organization of care are gaining importance in the field of ARM. This guideline gives practical guidance on how to achieve better communication and collaboration between all involved parties, applicable at the European level.

[Systematic review of individual biopsychosocial aspects of interventions during a physiological birth in primiparous women]

The birth process involves biopsychosocial aspects, the identification of which has been little researched. This systematic review aims to identify biopsychosocial aspects of interventions during physiological birth in first-time mothers and to assess the effectiveness of these interventions on birth outcomes.A systematic guideline search resulted in the definition of a physiological birth of first-time mothers with a singleton from the cephalic position at 37+0 to 42+0 weeks' gestation. A systematic literature search assessed intervention studies for evidence quality using the GRADE methodology. Structured content analysis according to Mayring was used to identify biopsychosocial aspects.18 bio-organic, psychological and sociological aspects were identified from 20 studies. The quality of evidence was mostly low to very low due to inadequate reporting of fetal and maternal outcomes and characteristics. Moderate confidence was shown for midwifery care and aromatherapy in increasing spontaneous labor, and transcutaneous electrical nerve stimulation in improving satisfaction, subjective pain perception and APGAR score. Identified biopsychosocial aspects enable a multidimensional assessment of physiological birth and could lead to a biopsychosocial care model. Insufficient quality of evidence does not allow the derivation of specific interventions. Studies in obstetrics should use defined endpoints and characteristics to improve the quality of evidence.

Clinical Practice Guideline for detection and management of diabetic kidney disease: A consensus report by the Spanish Society of Nephrology

To address all the changes in the management of people with diabetes (DM) and chronic kidney disease (CKD), under the auspices of the Spanish Society of Nephrology (SEN), the Spanish Diabetic Nephropathy Study Group (GEENDIAB) decided to publish an updated Clinical Practice Guideline for detection and management of diabetic kidney disease (DKD). It is aimed at a wide audience of clinicians treating diabetes and CKD. The terminology of kidney disease in diabetic patients has evolved toward a more inclusive nomenclature that avoids underdiagnosis of this entity. Thus, the terms "diabetes and kidney disease" and "diabetic kidney disease" are those proposed in the latest KDIGO 2022 guidelines to designate the whole spectrum of patients who can benefit from a comprehensive therapeutic approach only differentiated according to eGFR range and albuminuria. Recommendations have been divided into five main areas of interest: Chapter 1: Screening and diagnosis of diabetic kidney disease, Chapter 2: Metabolic control in people with diabetes and CKD, Chapter 3: Blood pressure control in people with diabetic kidney disease, Chapter 4: Treatment targeting progression of CKD in people with diabetic kidney disease, and Chapter 5: Antiplatelet or anticoagulant therapy in people with diabetes and CKD. World Health Organization (WHO) recommendations for guideline development were followed to report this guideline. Systematic reviews were carried out, with outcome ratings and summaries of findings, and we reported the strength of recommendations following the "Grading of Recommendations Assessment, Development and Evaluation" GRADE evidence profiles.

Management of Diabetes and Hyperglycemia in the Hospital: A Systematic Review of Clinical Practice Guidelines

BACKGROUND

Inpatient hyperglycemia is common among adults, and management varies.

PURPOSE

To systematically identify guidelines on inpatient hyperglycemia management.

DATA SOURCES

MEDLINE, Guidelines International Network, and specialty society websites were searched from 1 January 2010 to 14 August 2024.

STUDY SELECTION

Clinical practice guidelines pertaining to blood glucose management in hospitalized adults were included.

DATA EXTRACTION

Two authors screened articles and extracted data, and three assessed guideline quality. Recommendations on inpatient monitoring, treatment targets, medications, and care transitions were collected.

DATA SYNTHESIS

Guidelines from 10 organizations met inclusion criteria, and 5 were assessed to be of high quality per the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument. All guidelines recommended monitoring blood glucose for patients with diabetes and nine for admission hyperglycemia. Eight guidelines recommended an upper blood glucose target of 180 mg/dL, five with a lower limit of 100 mg/dL and three of 140 mg/dL. Guidelines were in agreement on using capillary blood glucose monitoring, and three guidelines included discussion of continuous monitoring. Hyperglycemia treatment with basal-bolus insulin alone (n = 3) or with correction (n = 5) was most commonly recommended, while sliding scale insulin was advised against (n = 5). Guidance on use of oral diabetes medications was inconsistent. Five guidelines included discussion of transitioning to home medications. Recommendations for hypoglycemia management and diabetes management in older adults were largely limited to outpatient guidance.

LIMITATIONS

Non-English-language guidelines were excluded.

CONCLUSIONS

While there is consensus on inpatient blood glucose monitoring and use of basal-bolus insulin, there is disagreement on treatment targets and use of home medications and little guidance on how to transition treatment at discharge.

ERN eUROGEN Guidelines on the Management of Anorectal Malformations Part III: Lifelong Follow-up and Transition of Care

INTRODUCTION

 Anorectal malformations (ARMs) are complex congenital anomalies of the anorectal region, oftentimes also affecting the genitourinary system. Although successful surgical correction can often be achieved in the neonatal period, many children will experience functional problems in the long term. The European Reference Network for rare and complex urogenital conditions (eUROGEN) assembled a panel of experts to address these challenges and develop comprehensive guidelines for the management of ARM.

METHODS

 The Dutch Quality Standard for ARM served as the foundation for the development of guidelines applicable on a European level. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from 7 European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected and recommendations were formed considering the current evidence and/or expert consensus.

RESULTS

 Lifelong follow-up, integration, and transition of care were assessed. A total of eight new studies were identified. The panel adapted 18 recommendations, adopted 6, and developed 6 de novo. Overall, the level of evidence was considered low.

CONCLUSION

 Successful lifelong follow-up and transition of care require a dedicated team of pediatric and adult specialist and an individually tailored patient-centered approach. This guideline summarizes the best available evidence on follow-up of ARM patients and provides guidance for the development of structured transition programs.

Evidence-Based Guidelines for Keratorefractive Lenticule Extraction Surgery

TOPIC

Development of evidence-based guidelines for keratorefractive lenticule extraction (KLEx).

CLINICAL RELEVANCE

Keratorefractive lenticule extraction refers to various corneal refractive procedures involving removal of refractive lenticules of intrastromal corneal tissue, typically through a small incision, eliminating creation of a corneal flap. This technique has gained popularity rapidly; however, no clinical practice guidelines exist.

METHODS

These evidence-based guidelines were developed following the World Health Organization guidebook using the Appraisal of Guidelines for Research and Evaluation II tool and adhering to the Reporting Items for Practice Guideline in Healthcare statement. The body of evidence was drawn from 8 literature databases, 5 clinical guideline databases, and 2 academic organizations. Recommendations were developed via a Delphi consensus of 44 global experts in refractive surgery, cornea, retina, glaucoma, and optometry. The certainty of evidence, balance of benefits and harms, patient preferences and values, and economic evaluations were considered fully. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and recommendation strengths.

RESULTS

From 385 initial clinical questions, 15 were identified, prompting a review of 250 717 studies, with 609 included for conducting and updating 26 and 2 systematic reviews, respectively. Subsequently, consensus was reached on 38 recommendations for preoperative screening, candidate selection, intraoperative quality control, operating principles, postoperative monitoring, and complication management. For KLEx, an effective and accurate refractive correction is attributed to various factors such as corneal thickness, degree of myopia, treatment nomogram, and optical zone. For complications that could affect vision, comprehensive and effective management strategies were proposed, particularly for wrong-plane dissection and difficult lenticule removal, suction loss, and perioperative infection. Customized surgical planning protocols and operative techniques were analyzed. Among all recommendations, 29 (76%) were labelled as strong, each externally reviewed. The corneal biomechanical properties may help to improve safety and predictability, although they need further validation. Several research gaps for enhancing KLEx safety were also revealed.

CONCLUSIONS

These guidelines provide evidence-based recommendations for KLEx in clinical practice, such as for preoperative screening for keratoconus, surgical planning, and management and prevention of complications and infection. The guidelines are expected to minimize the complications and achieve better outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

European Reference Network eUROGEN Guidelines on the Management of Anorectal Malformations, Part II: Treatment

INTRODUCTION

 Anorectal malformations (ARMs) are rare birth defects affecting the anorectum and oftentimes the genitourinary region. The management of ARM patients is complex and requires highly specialized surgical and medical care. The European Reference Network eUROGEN for rare and complex urogenital conditions aimed to develop comprehensive guidelines for the management of ARM applicable on a European level.

METHODS

 The Dutch Quality Standard for ARM served as the basis for the development of guidelines. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from seven European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected and recommendations were formed considering the current evidence, expert opinion, and the European context.

RESULTS

 Surgical and medical treatment of ARM, postoperative instructions, toilet training, and management of fecal and urinary incontinence were addressed. Seven new studies were identified. The panel adapted 23 recommendations, adopted 3, and developed 8 de novo. The overall level of newly found evidence was considered low.

CONCLUSION

 Treatment of ARM patients requires a multidisciplinary team and expertise about anatomical and surgical aspects of the disease, as well as long-term follow-up. This guideline offers recommendations for surgical and medical treatment of ARM and associated complications, according to the best available evidence and applicable on a European level.

Methodological Quality and Content of Guidelines on Early Childhood Allergy Prevention: A Systematic Assessment and Content Analysis

Recommendations on Early Childhood Allergy Prevention (ECAP) are found in Clinical Practice Guidelines (CPG) and Food-Based Dietary Guidelines (FBDG). This synthesis of guidelines aims to compare the methodological quality and content of recommendations in CPGs and FBDGs for ECAP. We searched MEDLINE, the FAO directory of FBDGs and other guideline databases, including the Association of the Scientific Medical Societies in Germany (AWMF), the WHO and the Guideline International Networks database on clinical guidelines (GIN) for CPGs and FBDGs about ECAP and child nutrition. Guidelines had to be published from 2010 onwards, target infants or pregnant/breastfeeding women and contain recommendations on primary preventative interventions to decrease the onset of IgE-mediated allergies, including atopic eczema or asthma. We retrieved a sample of 36 guidelines (23 CPGs, 13 FBDGs) and assessed their methodological quality with the Appraisal of Guidelines for Research and Evaluation tool (AGREE) II. On a subset of recommendations, we performed an in-depth analysis by the type of intervention for direction and strength of recommendation and level of evidence. Descriptive analysis was conducted with SPSS 27. CPGs score higher than FBDGs in most AGREE domains (3, 4, 5 and 6). The 36 guidelines contain 287 recommendations on ECAP, with 70 addressing the introduction of complementary foods and common allergens. We found only slight differences between those recommendations in CPGs and FBDGs. FBDGs on ECAP are of lower quality than CPGs. This does not affect their recommendations on the introduction of complementary foods and common allergens but may compromise their trustworthiness.

AGREE II Evaluation of Clinical Practice Guidelines on Generalized Cancer Pain Management

PURPOSE

While several clinical practice guidelines (CPGs) exist to guide clinical decision-making in patients with generalized cancer pain, to date there has been no comprehensive review of their quality. Our aim was to address this deficiency via the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.

DESIGN

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline-based systematic literature search followed by AGREE II appraisal of identified CPGs.

METHODS

Embase, MEDLINE via PubMed, and Scopus were searched from inception to March 3, 2021, for relevant CPGs. Four authors (FR, AR, JN, JH) independently performed assessments and evaluations of the selected CPGs using the AGREE II instrument. Scaled domain percentage scores were calculated with 60% as the satisfactory quality threshold. Intraclass correlation coefficients (ICCs) were also calculated to assess interrater reliability.

RESULTS

Twelve guidelines were selected for inclusion. Two guidelines were classified high quality, three guidelines as average quality, and seven as low quality. Domains of clarity of presentation (82.41% ± 18.20%) and scope and purpose (56.48% ± 30.59%) received the highest mean scores, while domains of applicability (44.53% ± 26.61%) and stakeholder involvement (36.81% ± 21.24%) received the lowest. ICCs showed high consistency between reviewers (range 0.85-0.98).

CONCLUSIONS

Most CPGs for generalized cancer pain are of low quality. Future guidelines can be improved by better-defining scope and purpose, stakeholder involvement, rigor of development, applicability, and editorial independence during development.

CLINICAL IMPLICATIONS

We hope these critiques improve the quality of published guidelines to promote an improved quality of care and method to measure quality outcomes.

Alpha-1-Antitrypsin Deficiency Targeted Testing and Augmentation Therapy: A Canadian Thoracic Society Meta-Analysis and Clinical Practice Guideline

Alpha-1-antitrypsin (A1AT) deficiency is a common hereditary disorder associated with increased risk of developing chronic obstructive pulmonary disease (COPD). Many individuals with severe A1AT deficiency go undiagnosed, or are diagnosed late, and fail to benefit from disease-specific counseling and modifying care. Since the 2012 Canadian Thoracic Society (CTS) A1AT deficiency clinical practice guideline, new approaches to optimal diagnosis using modern genetic testing and studies of A1AT augmentation therapy have been published. We performed a systematic review and meta-analysis, which along with expert clinical input, informed recommendations. We conditionally recommend testing for A1AT deficiency in all individuals with COPD at the time of diagnosis, individuals with adult-onset asthma with persistent airway obstruction, and individuals with unexplained bronchiectasis. We suggest genetic testing with DNA sequencing of SERPINA1 gene as the initial test for individuals with high clinical suspicion for A1AT deficiency, and initial measurement of serum A1AT levels in individuals with moderate clinical suspicion of A1AT deficiency, followed by genetic testing with DNA sequencing of SERPINA1 gene if A1AT level is <23 μmol/L (<1.2 g/L). Following identification of an abnormal gene for A1AT in individuals, whether heterozygote or homozygote, we suggest first-degree relatives be provided genetic counseling and offered testing for A1AT deficiency. The panel conditionally recommends A1AT augmentation therapy to patients who do not smoke or who formerly smoked with COPD (forced expiratory volume in 1 s [FEV1] < 80% predicted; associated with emphysema), with documented deficiency genotypes and severely reduced A1AT level (< 11 μmol/L or < 0.57 g/L) in addition to receiving optimal pharmacological and nonpharmacological therapies for COPD.

European Academy of Neurology (EAN)/European Federation of Autonomic Societies (EFAS)/International Neuro-Urology Society (INUS) Guidelines for Practising Neurologists on the Assessment and Treatment of Neurogenic Urinary and Sexual Symptoms (NEUROGED Guidelines)

BACKGROUND

Urinary and sexual symptoms are common following neurological disease, and we aimed to develop multidisciplinary inter-society evidence-based management guidelines.

METHODS

The ADAPTE framework was used, and a systematic search of guidelines published in different languages was performed. Guidelines, consensus statements, and systematic reviews were included, and guideline quality was appraised using AGREE II. Patient representatives reviewed the relevance and suitability of recommendations. A modified Delphi process integrating the Evidence to Decision framework adapted from GRADE and the Oxford Centre for Evidence Based Medicine system was used to reach consensus on recommendation wording and strength.

RESULTS

Recommendations were drafted, using guidelines/consensus statements (59 urinary, 50 sexual), systematic reviews (8 urinary, 2 sexual) and others (7 urinary,13 sexual), and wordings/strengths achieved at least 80% consensus through 2 Delphi rounds. Eleven evidence-based recommendations, 19 good practice statements, and 8 consensus-based recommendations were made. Individuals with neurological diseases should be asked about urogenital symptoms and undergo targeted physical examination when appropriate. Urinary symptom assessments include urinalysis, bladder diary completion, and post-void residual volume measurement. Treatments include fluid intake optimization, pelvic physiotherapy, tibial nerve stimulation, and oral medications. Urinary retention is managed by intermittent catheterization. Antibiotics should not be recommended to treat asymptomatic bacteriuria. Suprapubic catheterization is preferred for long-term catheterization. A comprehensive sexual history should be taken, focusing on multidimensional factors affecting sexual health. Treatments include lubricants, vibrators, and phosphodiesterase-5 inhibitors. Red flag symptoms warrant a shared-care approach with specialist colleagues.

CONCLUSIONS

The 38 NEUROGED recommendations will guide neurologists to comprehensively manage urogenital symptoms reported by individuals with neurological diseases.

Impact of postpartum physical activity on cardiometabolic health, breastfeeding, injury and infant growth and development: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between postpartum physical activity and maternal postnatal cardiometabolic health, breastfeeding, injury, and infant growth and development.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Eight online databases were searched up until 12 January 2024.

ELIGIBILITY CRITERIA

Studies of all designs in all languages were eligible (except case studies and reviews) if they contained information on the population (postpartum people), intervention (frequency, intensity, duration, volume, or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+co-intervention'), comparator (no or low volumes of physical activity), and outcomes: hypertension, diabetes, cardiometabolic risk factors (systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, high density lipoproteins, low density lipoproteins, and triglycerides, glycated hemoglobin (HbA1C), glucose and insulin concentration), breastfeeding (breast milk quality and volume), infant growth (length and weight) and development, or postpartum injury.

RESULTS

46 unique studies (n=8766 participants) from 20 countries were included. Moderate certainty of evidence showed exercise+co-interventions reduced the odds of developing diabetes by 28% (7 randomised controlled trials (RCTs), n=2496; OR 0.72 95% CI 0.54, 0.98, I2 12%), reduced SBP (10 RCTs, n=2753; mean difference (MD) -2.15 95% CI -3.89 to -0.40, I2 73%) and DBP (9 RCTs, n=2575; MD -1.38 95% CI -2.60 to -0.15, I2 66%) compared with controls. Infant growth and development, breast milk quality and quantity, and risk of injury were not different between exercise and control groups.

CONCLUSIONS

Physical activity improves cardiometabolic health without adversely impacting breast milk supply or quality, infant growth or maternal injury.

Impact of exercise on musculoskeletal pain and disability in the postpartum period: a systematic review and meta-analysis

OBJECTIVE

To examine the impact of exercise on musculoskeletal pain (low back pain (LBP), pelvic girdle pain (PGP), lumbopelvic pain (LBPP) and bodily pain) and kinesiophobia during the postpartum period.

DESIGN

Systematic review with random effects meta-analysis.

STUDY ELIGIBILITY CRITERIA

Online databases were searched from database inception to 12 January 2024. Studies of all designs (except case studies) of any publication date or language were included if they contained information on the population (women and people in the first year postpartum), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ('exercise-only') or in combination with other interventions (eg, electrotherapy, infrared irradiation, ultrasound; 'exercise+cointervention')), comparator (no exercise or different exercise measures) and outcome (symptom severity of LBP/PGP/LBPP, related disability, bodily pain and kinesiophobia).

RESULTS

37 studies (N=3769 participants) from 15 countries were included. Moderate certainty evidence showed that exercise-only interventions, including various strengthening exercises targeting the trunk muscles, were associated with a greater reduction in LBPP symptom severity (4 randomised controlled trials (RCTs), n=210; mean difference -2.21 points (on a 0-10 Visual Analogue Scale) 95% CI -3.33 to -1.08) and related disability (6 RCTs, n=296; standardised mean difference -1.17, 95% CI -1.92 to -0.43; large effect size) as compared with no exercise. Similar results were found for bodily pain (2 RCTs, n=318). Evidence was limited and inconclusive regarding the impact of exercise interventions on kinesiophobia.

CONCLUSION

Postnatal exercises, including a variety of muscular strengthening exercises targeting the trunk muscles, decrease the symptom severity of LBPP and related disability.

Impact of postpartum physical activity on maternal anthropometrics: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis examined the relationship between postpartum exercise and maternal postpartum anthropometrics.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

STUDY ELIGIBILITY CRITERIA

Online databases were searched from database inception until 12 January 2024. Randomised controlled trials (RCTs) written in any language were eligible if they contained information on the population (postpartum women and people); intervention (frequency, intensity, duration, volume or type of exercise, alone ('exercise-only') or in combination with other interventions (eg, dietary; 'exercise+cointervention')); comparator (no exercise) and outcomes (anthropometric measures including weight, postpartum weight retention (PPWR), body mass index (BMI), fat mass, lean body mass (LBM), body fat percentage, waist circumference, hip circumference or waist-hip ratio).

RESULTS

64 RCTs (n=12 684 participants) from 20 countries were included. Moderate to high certainty of evidence showed that exercise-only interventions reduced weight by 1.34 kg (18 studies, n=771; 95% CI -2.06 to -0.61, I2 0%), BMI by 0.73 kg/m2 (14 studies, n=662; 95% CI -1.21 to -0.25, I2 60%) and fat mass by 1.55 kg (5 studies, n=135; 95% CI -3.01 to -0.09, I2 0%) compared with no exercise. The duration of the exercise interventions ranged from 3 months to 3 years. Dose-response analysis found 560 MET-min/week of exercise (eg, 120 min/week of brisk walking) was associated with 1 kg/m2 reduction in BMI. Low certainty of evidence showed that exercise-only interventions had no effect on LBM (5 RCTs, n=135; standardised mean difference -0.13; 95% CI -0.48, 0.21, I2 0%) compared with no exercise.

CONCLUSIONS

These findings highlight physical activity as an effective intervention to improve postpartum anthropometrics and reduce PPWR.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Appraisal of guidelines and variations in recommendations on drug therapy for invasive aspergillosis prevention and treatment

Background

In recent years, many guidelines related to aspergillosis have been published worldwide. However, no studies have applied assessment tools to systematically evaluate the quality of these guidelines.

Objectives

This study aimed to assess the quality of clinical practice guidelines and compared their recommendations related to drug therapy for the prevention and treatment of invasive aspergillosis.

Methods

Electronic databases, guideline development organizations, and professional society websites were searched to identify clinical practice guidelines for invasive aspergillosis published between 1 January 2013, and 12 September 2023. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Recommendations for the drug prevention and treatment of invasive aspergillosis were extracted and descriptively analyzed.

Results

Among the 18 included clinical practice guidelines, the median scores and interquartile range for each AGREE II domain were: scope and purpose, 76.39% (69.1%, 80.21%); stakeholder involvement, 59.72% (50.35%, 67.02%); rigor of development, 64.58% (44.4%, 72.27%); clarity and presentation, 81.25% (68.06%, 91.32%); applicability, 41.67% (36.46%, 47.92%); and editorial independence, 76.05% (50%, 87.5%). Voriconazole and isavuconazole are recommended as first-line therapy for invasive aspergillosis currently. Posaconazole remains the first choice for invasive aspergillosis prophylaxis in patients with hematological malignancies.

Conclusion

The development processes and reporting of invasive aspergillosis -related clinical practice guidelines varied and their quality requires improvement. The guideline recommendations have changed since the approval of isavuconazole.

Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis

OBJECTIVE

To examine the effect of exercise during the first year postpartum on pelvic floor disorders and diastasis recti abdominis.

DESIGN

Systematic review with random effects meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov were searched until 12 January 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of all designs (except case studies) and languages were included if they contained information on the Population (individuals in the first year postpartum), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise alone ('exercise-only') or in combination with other intervention (eg, biofeedback; 'exercise+co-intervention')), Comparator (no exercise or different exercise measures) and Outcome (symptom severity and risk of urinary incontinence, anal incontinence, pelvic organ prolapse, diastasis recti abdominis and sexual function).

RESULTS

65 studies (n=21 334 participants) from 24 countries were included. 'Moderate' certainty of evidence revealed that pelvic floor muscle training reduced the odds of urinary incontinence by 37% (seven randomised controlled trials (RCTs), n=1930; OR 0.63, 95% CI 0.41 to 0.97, I2 72%) and pelvic organ prolapse by 56% (one RCT, n=123; OR 0.44, 95% CI 0.21 to 0.91) compared with control groups. 'Low' certainty of evidence showed a greater reduction in inter-rectus distance measured at rest and during a head lift following abdominal muscle training compared with no exercise. Evidence on the effect of exercise on the risk of anal incontinence and diastasis recti abdominis, as well as the severity of anal incontinence, urinary incontinence, pelvic organ prolapse and sexual function, is limited.

CONCLUSION

Evidence supports the effectiveness of postpartum pelvic floor muscle training in reducing the odds of urinary incontinence and pelvic organ prolapse and postpartum abdominal exercise training in reducing inter-rectus distance.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Impact of postpartum physical activity on maternal depression and anxiety: a systematic review and meta-analysis

OBJECTIVE

To examine the influence of postpartum exercise on maternal depression and anxiety.

DESIGN

Systematic review with random effects meta-analysis and meta-regression.

DATA SOURCES

Online databases up to 12 January 2024, reference lists, recommended studies and hand searches.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and non-randomised interventions of any publication date or language were included if they contained information on the Population (postpartum people), Intervention (subjective or objective measures of frequency, intensity, duration, volume, type, or mode of delivery of exercise), Comparator (no exercise or different exercise measures), and Outcome (postpartum depression, anxiety prevalence, and/or symptom severity).

RESULTS

A total of 35 studies (n=4072) were included. Moderate certainty evidence from RCTs showed that exercise-only interventions reduced the severity of postpartum depressive symptoms (19 RCTs, n=1778, SMD: -0.52, 95% CI -0.80 to -0.24, I2=86%, moderate effect size) and anxiety symptoms (2 RCTs, n=513, SMD: -0.25, 95% CI -0.43 to -0.08, I2=0%, small effect size), and the odds of postpartum depression by 45% (4 RCTs, n=303 OR 0.55, 95% CI 0.32 to 0.95, I2=0%) compared with no exercise. No included studies assessed the impact of postpartum exercise on the odds of postpartum anxiety. To achieve at least a moderate reduction in the severity of postpartum depressive symptoms, postpartum individuals needed to accumulate at least 350 MET-min/week of exercise (eg, 80 min of moderate intensity exercise such as brisk walking, water aerobics, stationary cycling or resistance training).

CONCLUSIONS

Postpartum exercise reduced the severity of depressive and anxiety symptoms and the odds of postpartum depression.

Investigator-initiated versus industry-sponsored trials - visibility and relevance of randomized controlled trials in clinical practice guidelines (IMPACT)

BACKGROUND

The goal of evidence-based medicine is to make clinical decisions based on the best available, relevant evidence. For this to be possible, studies such as randomized controlled trials (RCTs), which are widely considered to provide the best evidence of all forms of primary research, must be visible and have an impact on clinical practice guidelines. We further investigated the impact of publicly and commercially sponsored RCTs on clinical practice guidelines by measuring direct and indirect impactful citations and the time to guideline impact.

METHODS

We considered the sample from the IMPACT study, where a total of 691 RCTs (120 German investigator-initiated trials (IITs), 200 international IITs, 171 German industry-sponsored trials (ISTs) and 200 international ISTs) was sampled from registries (DFG-/BMBF-Websites, the German Clinical Trials Register, and from ClinicalTrials.gov) and followed prospectively. First, all eligible IITs were sampled. Then, ISTs were randomly selected while ensuring balance across certain trial characteristics. Next, the corresponding publications in the form of original research articles were identified. A search was then conducted for (1) systematic reviews (SRs) citing these articles and (2) clinical practice guidelines (CPGs) that cited either the original articles or the SRs. The methods and results of this effort were already published. In this investigation we aimed to better characterize the impact of RCTs in CPGs. Therefore, we identified all citations of the original articles and SRs in the citing CPGs and classified them into impactful and non-impactful. This allowed us to calculate an estimate for the guideline impact of a trial. In addition, we estimated the time-to-guideline-impact, defined as the time to a direct and indirect impactful citation in a CPG. Direct means that the publication of a trial was cited in the main text of a CPG. Indirect means that the publication was cited and included in the findings of a SR and the SR was cited in the main text of a CPG. We also investigated to what extent pre-defined study characteristics influenced the guideline impact using multivariable negative binomial regression as well as the time-to-guideline impact using multivariable Cox proportional hazards regression.

RESULTS

Overall, 22% of RCTs impacted a CPG. For international ISTs, only 15% of trials had an impact in CPGs. Overall, of the 405 associated guidelines, 331 were impacted. Larger trials were associated with more impactful main text citations in CPGs and earlier time-to-guideline impact, while international industry-sponsored trials were associated with smaller impact on CPGs and longer time-to-guideline impact. IITs funded by governmental bodies in Germany reached an impact on CPGs that is on par with German ISTs or international IITs and ISTs.

CONCLUSION

This study demonstrated that a considerable number of trials previously identified as being linked to CPGs have had impact in those CPGs (85%). International ISTs seem to have a lower impact on CPGs, and fewer of them influence CPGs at all.

Computer aided detection and diagnosis of polyps in adult patients undergoing colonoscopy: a living clinical practice guideline

CLINICAL QUESTION

In adult patients undergoing colonoscopy for any indication (screening, surveillance, follow-up of positive faecal immunochemical testing, or gastrointestinal symptoms such as blood in the stools) what are the benefits and harms of computer-aided detection (CADe)?

CONTEXT AND CURRENT PRACTICE

Colorectal cancer (CRC), the third most common cancer and the second leading cause of cancer-related death globally, typically arises from adenomatous polyps. Detection and removal of polyps during colonoscopy can reduce the risk of cancer. CADe systems use artificial intelligence (AI) to assist endoscopists by analysing real-time colonoscopy images to detect potential polyps. Despite their increasing use in clinical practice, guideline recommendations that carefully balance all patient-important outcomes remain unavailable. In this first iteration of a living guideline, we address the use of CADe at the level of an individual patient.

EVIDENCE

Evidence for this recommendation is drawn from a living systematic review of 44 randomised controlled trials (RCTs) involving more than 30 000 participants and a companion microsimulation study simulating 10 year follow-up for 100 000 individuals aged 60-69 years to assess the impact of CADe on patient-important outcomes. While no direct evidence was found for critical outcomes of colorectal cancer incidence and post-colonoscopy cancer incidence, low certainty data from the trials indicate that CADe may increase positive endoscopy findings. The microsimulation modelling, however, suggests little to no effect on CRC incidence, CRC-related mortality, or colonoscopy-related complications (perforation and bleeding) over the 10 year follow-up period, although low certainty evidence indicates CADe may increase the number of colonoscopies performed per patient. A review of values and preferences identified that patients value mortality reduction and quality of care but worry about increased anxiety, overdiagnosis, and more frequent surveillance.

RECOMMENDATION

For adults who have agreed to undergo colonoscopy, we suggest against the routine use of CADe (weak recommendation).

HOW THIS GUIDELINE WAS CREATED

An international panel, including three patient partners, 11 healthcare providers, and seven methodologists, deemed by MAGIC and The BMJ to have no relevant competing interests, developed this recommendation. For this guideline the panel took an individual patient approach. The panel started by defining the clinical question in PICO format, and prioritised outcomes including CRC incidence and mortality. Based on the linked systematic review and microsimulation study, the panel sought to balance the benefits, harms, and burdens of CADe and assumed patient preferences when making this recommendation UNDERSTANDING THE RECOMMENDATION: The guideline panel found the benefits of CADe on critical outcomes, such as CRC incidence and post-colonoscopy cancer incidence, over a 10 year follow up period to be highly uncertain. Low certainty evidence suggests little to no impact on CRC-related mortality, while the potential burdens-including more frequent surveillance colonoscopies-are likely to affect many patients. Given the small and uncertain benefits and the likelihood of burdens, the panel issued a weak recommendation against routine CADe use.The panel acknowledges the anticipated variability in values and preferences among patients and clinicians when considering these uncertain benefits and potential burdens. In healthcare settings where CADe is available, individual decision making may be appropriate.

UPDATES

This is the first iteration of a living practice guideline. The panel will update this living guideline if ongoing evidence surveillance identifies new CADe trial data that substantially alters our conclusions about CRC incidence, mortality, or burdens, or studies that increase our certainty in values and preferences of individual patients. Updates will provide recommendations on the use of CADe from a healthcare systems perspective (including resource use, acceptability, feasibility, and equity), as well as the combined use of CADe and computer aided diagnosis (CADx). Users can access the latest guideline version and supporting evidence on MAGICapp, with updates periodically published in The BMJ.

International Consensus Guidelines on the Delineation of Radiation Therapy Target Volumes for Nasopharyngeal Carcinoma After Induction Chemotherapy Using a 2-Round Modified Delphi Survey

PURPOSE

Induction chemotherapy (ICT), a new standard in the management of locally advanced nasopharyngeal carcinoma (NPC), is increasingly used in endemic regions. Radiation therapy (RT) target volume delineation protocols and dose level prescriptions vary significantly in the literature. High-level evidence to support a particular approach is currently lacking. We developed an international consensus guideline toward harmonizing practices based on a literature review and expert opinion.

METHODS AND MATERIALS

The study entailed the following: consensus scope definition by focus group discussion (FGD); evidence gap identification by a scoping review of guidelines and literature reviews; evidence review and synthesis by a systematic review of experimental and observational studies and drafting of consensus statements by FGD; and consensus voting by modified Delphi process and FGD. The task force consisted of radiation oncologists from intermediate- and high-endemicity regions with expertise in treating NPC, evidence review, and consensus guideline development. The consensus panel consisted of relevant specialists from intermediate- and high-endemicity regions or with expertise in treating NPC. A modified e-Delphi method was used.

RESULTS

Four clinical situations after ICT for patients with NPC were selected for the consensus questions: optimal timing of chemoradiation; optimal imaging modalities for simulation and target volume delineation; optimal dose and fractionation; and RT target volume delineation. The consensus panel consisted of radiation oncologists (12), clinical oncologists (4), radiologists (3), a nuclear medicine specialist, medical physicists (2), and dosimetrists (2). The consensus guidelines were formulated after 2 rounds of Delphi voting and FGD; iterative revisions were made based on 2 rounds of internal review. The guidelines were subjected to external review and open commentary; further revisions were made if the consensus vote was not invalidated.

CONCLUSIONS

An international consensus guideline on delineating RT target volumes and corresponding dose levels in post-ICT NPC, as well as timing and modalities for imaging, was developed to help harmonize practices and enhance the comparability of interpretations of reported outcomes.

A comparison and AGREE II analysis of the revised Society for Vascular Surgery/American Venous Forum/American Vein and Lymphatic Society and European Society for Vascular Surgery clinical practice guidelines in the management of varicose veins

OBJECTIVE

The aim of this study was to compare the Society for Vascular Surgery/American Venous Forum/American Vein and Lymphatic Society (SVS/AVF/AVLS) and the European Society for Vascular Surgery (ESVS) revised Clinical Practice Guidelines (CPGs) for treatment of C2 varicose veins (VVs) by an analysis of content, methodology, level of evidence, and strength of evidence as well as by Appraisal of Guidelines for Research and Evaluation II (AGREE II) analysis.

METHODS

The 2022 SVS/AVF/AVLS guidelines for VVs were compared with the 2022 ESVS CPGs on VVs for: specific methodology, evidence development, strength of recommendation, and level (quality) of evidence. Additionally, an AGREE II analysis was performed to compare the two guidelines. These guidelines were scored on six different domains as well as overall quality using a 7-point Likert scale according to the AGREE II methodology.

RESULTS

The two CPGs differed in methodology and scope of content. The two guidelines varied significantly on their ratings of levels of evidence as well as their overall strengths of recommendations. The AGREE II analysis found that both guidelines scored as high quality in the domains of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, editorial independence, and overall assessment. For the domain of applicability, ESVS guidelines (65.28%) scored significantly higher than SVS/AVF/AVLS guidelines (51.39%; P ≤ .05).

CONCLUSIONS

Although the methodology differed significantly between both guidelines, the overall conclusions remained similar, and both guidelines were rated as high quality by AGREE II analysis.

Clinical practice guidelines for dementia contain few recommendations relevant to the physiotherapy scope of practice and are of varying quality: a systematic review

BACKGROUND

The content and quality of dementia guideline recommendations relevant to physiotherapy remains unknown.

CLINICAL QUESTION

What is the content and methodological quality of dementia guideline recommendations within the physiotherapy scope of practice?

DESIGN

Systematic review of clinical practice guidelines.

DATA SOURCES

MEDLINE, Embase, CINAHL, AgeLine, Google, guideline databases, and relevant websites (to January 2025).

STUDY SELECTION

Guidelines in English, screened through a three-phase process by two independent reviewers, were eligible if recommendations were relevant to adults with dementia and within the physiotherapy scope of practice.

DATA APPRAISAL AND SYNTHESIS METHODS

Guideline characteristics and recommendation content were extracted. Recommendations using GRADE methodology with certainty of evidence and strength of recommendation scores were synthesised. Quality was assessed using AGREE II and AGREE-REX.

RESULTS

Twenty-one relevant guidelines were identified. Twelve used GRADE methodology, eight presented GRADE scores. Thirty-three recommendations with GRADE scores met the physiotherapy scope of practice, categorised into ten topics: exercise (n = 11), acupuncture (n = 1), psychosocial and environmental interventions (n = 1), tailored activities (n = 2), carer support (n = 3), pain management (n = 5), falls risk management (n = 1), outcomes and outcome measures (n = 4), care planning (n = 1), and care setting transitions (n = 4). Methodological quality of guidelines and recommendations varied significantly.

LIMITATIONS

Non-English language publications were excluded. Only recommendations presenting GRADE scores were synthesised.

CONCLUSION

Current dementia guidelines partially reflect the physiotherapy scope of practice. Varying methodological quality and inconsistent rating methods challenge interpretation and implementation. Robust physiotherapy-specific guidelines are needed to demonstrate the value of physiotherapy for people with dementia, and inform clinical practice, education, and policy.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Systematic Review Registration Number PROSPERO CRD42023412107. CONTRIBUTION OF THE PAPER.

2025 Canadian guideline for physical activity, sedentary behaviour and sleep throughout the first year post partum

This consensus aims to provide guidance for postpartum women and people, healthcare providers and exercise professionals on physical activity, sedentary behaviour and sleep throughout the first year postpartum. The development of this guideline followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and the Appraisal of Guidelines for Research and Evaluation II instrument. The Guideline Consensus Panel consisted of representatives from key professional groups, researchers and methodological experts. Literature was retrieved through searches of 12 online databases, and articles on maternal physical activity, sedentary behaviour or sleep in the first year after childbirth were eligible for inclusion if they reported on any of 21 maternal or infant health outcomes, which were prioritised considering the preferences and values of postpartum individuals. There was no restriction on language, and all study designs were eligible except for case studies. The certainty of evidence was rated using GRADE. This evidence review produced seven systematic reviews, which informed this consensus statement. A Delphi process was conducted to identify relative contraindications to postpartum moderate-intensity to vigorous-intensity physical activity, which informed the development of the Get Active Questionnaire for Postpartum. Evidence to decision tables were developed, and feedback on the recommendations was solicited from end users (healthcare providers, exercise professionals, researchers, policy organisations and postpartum women and people). Adhering to these consensus recommendations for postpartum women and people is likely to result in large improvements in psychological well-being, as well as pelvic, musculoskeletal and cardiometabolic health, and reduced fatigue, while not experiencing adverse events (moderate certainty evidence). Most end users indicated that following these recommendations would be feasible, acceptable and equitable, and likely to require minimal resources from individual and health systems perspectives. PROSPERO registration number CRD42022359282.

Domestic violence in pregnancy: a systematic review of clinical guidelines

BACKGROUND

Domestic violence is a public health concern and human rights violation affecting more than one-third of all pregnant women globally. Abused pregnant women need several interventions to reduce domestic violence and its negative consequences on mother and child. The purpose of this study was to determine the quality, scope, and consistency of clinical guidelines for managing domestic violence during pregnancy.

METHODS

This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Electronic databases of Scopus, PubMed, Embase, Web of Science, Up-to-date, Cochrane Library database, Google Scholar, and Guideline repositories, including NICE, SIGN, GAC, NHMRC, NGC, New Zealand Guidelines Group, TRIP, AHRQ, G-I-N, and MD Consult, using appropriate keywords were searched. Included studies were clinical guidelines containing recommendations about domestic violence in pregnancy and postpartum. Two reviewers used the AGREE II (Appraisal of Guidelines, Research, and Evaluation version 2) instrument to evaluate the quality of guidelines, and textual syntheses were used to appraise and compare the relevant recommendations. Out of 381 relevant published guidelines, 14 clinical guidelines were ultimately reviewed systematically.

RESULTS

Seven countries had a clinical guideline for domestic violence during pregnancy. None of the reviewed guidelines was rated > 75% across all domains of AGREE II while the highest-rated domains were scope, purpose, and clarity. Four related categories were recognized from the synthesis of recommendations within the appropriate guidelines. These consisted of an introduction, domestic violence in pregnancy, the role of health care professionals, and the resources. Recommendations for privacy and confidentiality, screening, identification, support, and documentation were the most commonly reported, which all of the guidelines advised them, suggesting the importance of identification of violence in pregnancy and support for abused pregnant women. 93% of the reviewed guidelines had recommendations on communication, support and building trust, child protection, and professional education and training.

CONCLUSION

The study findings suggest that there are currently gaps in clinical guidelines in various areas, including patterns of violence, the cycle of violence, identifying risk factors for violence during pregnancy, providing medical care, implementing home visitation programs, promoting self-care and empowerment, preventing violence, offering follow-up support, and conducting community education programs. Therefore, it is crucial to develop or adapt clinical guidelines for abused pregnant women, emphasizing their needs to ensure their safety and well-being.