Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument

IntroductionDiverticular disease is one of the most frequent reasons for attending emergency departments and surgical causes of hospital admission. In the past decade, many surgical and gastroenterological societies have published guidelines for the management of diverticular disease. The aim of the present study was to appraise the methodological quality of these guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool.MethodsPubMed, Embase, Cochrane Library and Google Scholar databases were searched systematically. The methodological quality of the guidelines was appraised independently by five appraisers using the AGREE II instrument.FindingsA systematic search of the literature identified 12 guidelines. The median overall score of all guidelines was 68%. Across all guidelines, the highest score of 85% was demonstrated in the domain ‘Scope and purpose’. The domains ‘Clarity and presentation’ and ‘Editorial independence’ both scored a median of 72%. The lowest scores were demonstrated in the domains ‘Stakeholder involvement’ and ‘Applicability’ at 46% and 40%, respectively. Overall, the National Institute for Health and Care Excellence (NICE) guidelines performed consistently well, scoring 100% in five of six domains; NICE was one of the few guidelines that specifically reported stakeholder involvement, scoring 97%. Generally, the domain of ‘Stakeholder involvement’ ranked poorly with seven of twelve guidelines scoring below 50%, with the worst score in this domain demonstrated by Danish guidelines at 25%.ConclusionSix of twelve guidelines (NICE, American Society of Colon & Rectal Surgeons (ASCRS), European Society of Coloproctology (ESCP), American Gastroenterological Association, German Society of Gastroenterology/German Society for General and Visceral Surgery (German), Netherlands Society of Surgery) scored above 70%. Only three, NICE, ASCRS and ESCP, scored above 75% and were voted unanimously by the appraisers for use as they are. Therefore, use of AGREE II may help improve the methodological quality of guidelines and their future updates.     

The assessment of clinical practice in osteopathic education: Is there a need to define a gold standard?

In the United Kingdom, assessment of clinical practice in medical education has proved to be a consistently difficult process. Central to these difficulties are issues surrounding the validity, reliability and feasibility of assessment of clinical practice that accurately reflect student abilities, whilst also representing ‘real life’ examples of patient care. Currently there is no consensus as to what might be regarded as best practice in clinical assessment within UK general medicine.Osteopathic institutions within the UK have an educational, professional and ethical obligation to ensure that their assessment satisfies all these criteria. However, it is arguable that there is also a need to ensure that standards exist between schools so that all students graduating from different programmes are comparably assessed to a standard that may be valid and reliable. Although the framework exists for the development of consensus for clinical assessment for osteopaths in the UK, there has been no formal discussion within the profession to date. A constructive and pragmatic approach in identifying a suitable standard in clinical education in the UK may be to identify best practice between schools as to how the assessment of students may be delivered, and then to identify how best to ensure that this assessment is consistently and appropriately delivered across schools.     

The role of osteopathy in clinical care: Broadening the evidence-base

Osteopathy is a system of health care practiced in various countries throughout the world that focuses on osteopathic manual techniques as a cornerstone of patient care. However, we still know little about the practice, role and use of osteopathy within the broader health system in most countries. With this in mind, this paper proposes a possible framework for advancing further research on this topic. The framework is divided into issues associated with core stakeholders including health consumers, osteopaths, other health professionals, and policymakers and funding bodies. The development of a rigorous health services research agenda around this topic has much to offer and the framework outlined here is offered with the hope of inspiring a broader field of inquiry into osteopathy in the clinical care setting.     

肾脏病临床实践指南多维度教学的探索

肾脏病临床实践指南对规范肾脏病的治疗、提高临床实践的同质性和改善预后起到重要作用。目前发布的肾脏病相关指南有300余项。肾脏病临床实践指南的特点包括：发布单位多，部分内容重复；亚专科分类细，交叉学科多；学科发展快，指南内容更新快慢不一。临床教学实践中针对实习医生、规范化培训轮转住院医生，进修医生及临床医学硕士专业学位研究生，设计多层次递进式教学模式，有助于强化循证医学理念，培养主动循证意识，规范医疗行为。     

Guidelines for the management of osteoporosis: the present and the future

Evidence-based guidelines are increasingly used in the management of osteoporosis and have the potential to produce uniformly high standards of clinical care across different sectors of the health service. National guidelines for the prevention and treatment of osteoporosis are now available in a number of countries and, although sharing similarities, also differ in some respects. This review considers the challenges involved in the development and implementation of guidelines and proposes a paradigm for the unification of guidelines in the future.     

The effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb: A literature review

BackgroundUltrasound is suggested as one of the treatment options available for soft tissue musculoskeletal conditions of the lower limb and to this end, the objective was to review the literature and evaluate the effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb.MethodsA search of the literature published between 1975 and February 2009 was carried out. All studies that fulfilled the inclusion criteria were quality assessed and scored using the Critical Appraisal Skills Programme (CASP) appraisal tool [1] for randomised controlled trials.ResultsTen studies out of a possible fifteen were included in the review. Only one trial was considered to be high quality (score 16+), three medium quality trials (score 11–15) were identified and six trials were considered to be low or poor quality (score ≤ 10). None of the six placebo-controlled trials found any statistically significant differences between true and sham ultrasound therapy.ConclusionThis literature review found that there is currently no high quality evidence available to suggest that therapeutic ultrasound is effective for musculoskeletal conditions of the lower limb.     

Systematic review of clinical practice guidelines for kidney disease in China: application of the Appraisal of Guidelines Research and Evaluation-China

Objective To evaluate the quality of clinical practice guidelines for kidney diseases in China and provide reference for selecting suitable high-quality guidelines for primary care and developing standardized guidelines. Methods The China Guideline Clearinghouse, China Biology Medicine disc, VIP Database, Wanfang Database and CNKI, and other resources were searched from January 2013 to July 2018. In accordance with the criteria for inclusion and exclusion, the published guidelines for kidney diseases were screened. The Appraisal of Guidelines Research and Evaluation-China (AGREE-China) was used to systematically assess the current status of domestic guidelines for kidney diseases. Results A total of 18 guidelines for kidney diseases were included, covering different types of kidney disease such as glomerulonephritis, nephrotic syndrome, end-stage renal disease and other diseases. The overall score ranged from 30 to 68, with an average score of 47.3. The average scores of these guidelines were 20.1, 12.8, 0.5, 9.9 and 3.9 in five review fields including scientificity/rigorism, effectiveness/safety, economy, availability/feasibility, and conflicts of interest, respectively. Of these 18 guidelines, 8(44.4%) guidelines were strongly recommended, and 10(55.6%) guidelines were weakly recommended. Conclusions There are still deficiencies in scientificity/rigorism and economy in current guidelines for kidney diseases in China. The AGREE-China can be used as an evaluation tool for guidelines for kidney diseases in accordance with China's situation, while its practicability and feasibility still need further verification and improvement.     

A clinician's guide to the treatment of foot burns occurring in diabetic patients

IntroductionDiabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burnsMethodsA multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets.ResultsKey aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen.ConclusionsBest outcomes for this high risk population will be attainable with an evidence based guideline.     

Evaluation of clinical guidelines for the management of end-stage renal disease in europe: the EU BIOMED 1 study.

BACKGROUND: There are wide national and international variations in the management of patients with end-stage renal disease (ESRD). The aim of this study was to develop, harmonize, implement, and evaluate consensus-based clinical guidelines for the management of renal anaemia and renal bone disease in patients with ESRD, and for the prevention and management of cytomegalovirus disease in renal transplant recipients across six renal centres in Europe. METHODS: The trial was a prospective, multicentre, randomized balanced incomplete block design. Nephrologists from the six European renal units were randomized to develop and implement guidelines for two out of the three conditions and to act as a control for the third condition. Data were collected pre- (1 year) and post- (9 months) intervention on aspects of patient monitoring, management, and outcome. RESULTS: Eight hundred and twenty-nine dialysis patients from the six European dialysis centres were included in the study. Multivariate analysis (adjusting for case-mix and secular trends) showed a significant increase in the number of monitoring events in the guideline group compared with control group (6%, 95% CI, 1-11%). There was no concomitant increase in either appropriate management or the number of favourable patient outcomes. CONCLUSIONS: In the first European collaboration on renal guidelines, the introduction of the guidelines improved the monitoring of the patients, but did not improve patient management or outcome. This study suggests the potential for creating clinical guidelines with the aim of standardizing treatment protocols across international boundaries, and improving the quality of the medical care provided.     

Clinical policies on the management of chronic kidney disease patients in Italy.

BACKGROUND: Recent studies have indicated that the implementation of international guidelines for the management of renal patients is suboptimal in Italy. The Italian Society of Nephrology (SIN) decided to undertake a multicentre study to obtain a clear picture of clinical policies on chronic kidney disease (CKD) in Italy. METHODS: A 76-item structured questionnaire, designed to evaluate the organization of clinical care, was administered to the director of each participating centre, within the context of a large observational trial in 100 Italian nephrology centres, collecting information on newly diagnosed CKD patients (K/DOQI stage 3-5) on conservative treatment. This paper reports the questionnaire results related to management of anaemia and bone metabolism disorders; assessment of renal function; creation of a vascular access for dialysis and referral of patients to a nephrologist. RESULTS: Clinical policies at the centre level deviated from guideline recommendations in 70% (timing of vascular access creation) to 25% (assessment of iron deficiency) of centres. Assessment of renal function differed from the recommended approach in 30% of centres; clinical policies related to anaemia and bone disease did not coincide with guideline standards in 50 and 40% of centres, respectively. Directors of renal unit estimates indicate that the creation of a vascular access occurs very late in 38% of patients and that referral to a nephrologist is late in approximately 40% of cases. CONCLUSION: This survey in Italy highlights important deviations of clinical policies at the centre level from guideline recommendations.     

Perioperative management of patients with musculoskeletal disease and for the burns patient

Musculoskeletal disease may present as isolated joint disease, a severe multisystem disorder or a neuromuscular disorder affecting the musculoskeletal system. Thorough preoperative assessment is essential to plan the surgical management of this group of patients. Assessment of the severity of cardiorespiratory disease may be difficult with severely limited mobility. The airway and neck may be involved so early anaesthetic opinion is essential. Drug therapy may need to be modified or stopped perioperatively. Intraoperative positioning and thermoregulation can be difficult to achieve and postoperative analgesia needs to be carefully planned to avoid respiratory depression in a vulnerable group.Patients with burns may present in the emergency department for urgent assessment or for early surgery to excise the burn and graft the defect. There may be an inhalational injury which if severe will require urgent treatment often with intubation and ICU care. A major burn is also a multisystem disorder and again there are challenges with airway management positioning and thermoregulation. These patients present for repeated surgeries and can suffer extreme emotional and psychological strain as a result of the burn insult.     

Comparison of Calcaneal Ultrasound and DXA to Assess the Risk of Corticosteroid-Induced Osteoporosis: A Cross-sectional Study

Patients on long-term oral corticosteroids have an increased risk of low bone mass and fragility fractures. Fracture risk rises soon after commencement of corticosteroid therapy and it is possible that these agents adversely influence bone architecture disproportionately to their effect on bone mass. The best means of assessing bone status in patients using corticosteroids remains uncertain, but quantitative ultrasound of the calcaneus may provide evidence of microarchitectural changes not detected by dual-energy X-ray absorptiometry (DXA). Patients with Crohn’s disease have an increased risk of low bone mineral density (BMD), the etiology of which is multifactorial but includes corticosteroid use. We studied 118 consecutive patients with Crohn’s disease, 21 of whom used continuous oral corticosteroids, 70 of whom were intermittent users, and 27 who had never used the drug. All patients received DXA of the lumbar spine, hip and calcaneus and quantitative ultrasound (QUS) of the calcaneus. The different techniques were compared using a femoral neck T-score ≤−1.5 as the threshold of corticosteroid-induced osteoporosis. When compared with the femoral neck T-score, there were no significant differences between the predictive values of lumbar spine DXA, calcaneal DXA or calcaneal QUS to identify low femoral neck BMD. However, the absolute T-score required to give similar discriminatory capacity to femoral neck T-score varied substantially (T=−0.81 to −1.5) between the different measurement techniques and sites. Received: 29 July 2000 / Accepted: 9 April 2001     

雌激素受体基因IVS401T/C变异在老年骨质疏松症发病中的作用

目的研究雌激素受体（ER）基因IVS1—401T／C变异与老年骨质疏松症的关系，以确定机体对雌激素作用的反应是否与其有关。方法对老年骨质疏松症患者及健康对照组采用PvuⅡ限制性核酸内切酶酶切目标片段判断ERα基因型，计算基因频率并进行比较。结果骨质疏松症患者中该位点核苷酸出现胞嘧啶核苷酸（C）的频率明显低于对照组（P〈0．05），ER T/T基因型是骨质疏松患者的独立危险因素，单纯分析女性受试者结果与之一致。结论ER基因IVS1—401T／C变异与老年骨质疏松症的发生有密切关系。