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??The interpretation of International Neural Monitoring Study Group guideline on external branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery(version 2013) SUN Hui??LIU Xiao-li??ZHAO Yi-shen. Division of Thyroid Surgery??China-Japan Union Hospital of Jilin University??Jilin Provincial Key Laboratory of Surgical Translational Medicine??Changchun 130033??China
Corresponding author??SUN Hui??E-mail??sunhui1229@163.com
Abstract Intraoperative neural monitoring has the potential to be utilized for identification of the external branch of the superior laryngeal nerve and functional assessment of its integrity??and contributes to patients’ voice preservation. A systematic search of the MEDLINE database (from 1950 to 2013) about the external branch of the superior laryngeal nerve was undertaken and supplemented by personal communication between members of the International Neural Monitoring Study Group. These guidelines are intended to improve the practice of neural monitoring of the external branch of the superior laryngeal nerve during thyroidectomy or parathyroidectomy. The guideline elaborated EBSLN on the aspects of anatomical classification, pathophysiology, intraoperative protection methods and indications in detail.     

An independent AGREE evaluation of the Occupational Medicine Practice Guidelines.

BACKGROUND AND CONTEXT: A large number of practice guidelines are being produced by numerous organizations. Health-care professionals need to critically evaluate these practice guidelines to understand whether they are well constructed and representative of the preponderance of evidence. The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague. PURPOSE: To evaluate the quality of the second edition of the practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM Guidelines). STUDY DESIGN/SETTING: Four appraisers used the AGREE (Appraisal of Guidelines Research and Evaluation) guideline evaluation instrument to evaluate the ACOEM Guidelines. METHODS: The Guidelines were evaluated with the AGREE guideline evaluation instrument. The AGREE instrument has been widely adopted around the world, and the authors recommended that it be adopted as the standard of guideline construction process evaluation in the United States. The instrument standardizes the quantitative assessment of quality for a guideline's development process across six domains that include: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. Scores from four assessors were collected and interpreted. Additionally, each evaluator selected one of four global assessment choices: "strongly recommended for use in practice," "recommended for use with some modification or proviso," "not recommended as suitable for use in practice," or "unsure". RESULTS: The ACOEM Guidelines scored highest in the dimensions that evaluated reporting of the guideline's scope and purpose (79.63) as well as clarity and presentation (86.81). The guideline scored much lower in the remaining areas that included stakeholder involvement (46.06), rigor of development (26.59), application (31.48), and editorial independence (19.17). The global assessment was unanimous with all four evaluators assessing the guideline as recommend with proviso. CONCLUSIONS: Many of the Guidelines recommendations were consistent with current literature and guidelines; however, the AGREE assessment instrument evaluates the guideline development process and not the content. All the evaluators thought the content of the guidelines was substantially better than the documentation of the guideline construction process. The ACOEM Guidelines appear to have content consistent with their stated objectives, but the reporting of the guidelines construction process, particularly the rigor of recommendation development, is flawed, and the recommendations may not be valid owing to possible evidence selection deficiencies. The reader should consider these flaws and limitations when using the guideline. The reader should consider utilizing guidelines of higher quality when possible. Future guidelines should incorporate better reporting and give closer attention to guideline construction.     

乳腺癌相关淋巴水肿评估与管理指南的质量评价与内容分析

目的 对乳腺癌相关淋巴水肿评估与管理的相关指南进行质量评价和内容分析,为我国本土化乳腺癌相关淋巴水肿评估与管理指南的制定提供参考.方法 计算机检索国内外指南网站、相关专业协会网站及中英文数据库,搜集乳腺癌相关淋巴水肿评估与管理相关指南.采用AGREE Ⅱ评价纳入指南的质量,并对各指南推荐意见进行汇总分析.结果 最终纳入...     

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??Highlights about the 5rd edition Japanese gastric cancer treatment guidelines HU Xiang. Department of General Surgery??the First Affiliated Hospital??Dalian Medical University??Dalian 116011??China
Abstract Version 5 of Japanese Gastric Cancer Treatment Guidelines (hereinafter referred to as the guideline) edited by the Japanese Gastric Cancer Association has been formally published in January 2018. This version guideline based analysis and discussion by the research results of the high level evidence-based medicine ??enriched the standard therapy of surgery and endoscopic treatment. The version 5 guideline has different characteristics of the times and progressiveness. And the guideline provides more accurate and scientific guidance and strategy for clinical medical treatment in the future.     

Evidence-based orthopaedics: a primer

Evidence-based medicine has evolved from the need of solving clinical problems. In contrast to the traditional paradigm of clinical practice, evidence-based medicine acknowledges that intuition, clinical experience, and pathophysiologic rationale are not sufficient for making the best clinical decisions. Although evidence-based medicine recognizes the importance of clinical experience, it includes the evaluation of evidence from clinical research and the integration of patients' values, preferences, and actions for best clinical decision-making. To optimize this process, evidence-based medicine advocates that a formal set of rules must accompany training and clinicians' common sense to interpret and apply evidence from clinical research results effectively. We describe the critical appraisal of studies related to prognosis and therapy or prevention building on an example relevant for the clinical orthopaedist. Based on the example, the authors describe how clinicians can apply measures of association and of intervention effects to their practice and patient care. The authors conclude with describing the appraisal of systematic reviews, their application to the development of practice guidelines, and the process of guideline development and recommendations.     

Introduction: guidelines and advisory development

Since 1992, the American Society of Anesthesiologists has produced 12 evidence-based practice guidelines, 2 practice advisories, and 3 guideline updates. These documents have assisted anesthesiologists and practitioners in many other specialties. Their brevity, practicality, and ease of use, coupled with a thorough and systematic evaluation of the evidence have been instrumental in bringing together the science and practice of medicine. The application of formal evidence-collection processes for literature and opinion and efficient analytic evaluations combine with the experience and practical knowledge of clinicians to produce widespread application of the guidelines.The evidence-based process developed by the ASA has been found to be adaptable to a wide variety of issues relating to clinical practice. The goal is to systematically collect and evaluate evidence from multiple sources and apply it ina comprehensive manner to the guideline recommendations. The ASA guideline and advisory development process is continuing to evolve in response to changes in medical technology, research, and practice. By providing synthesized evidence from multiple sources and robust clinical recommendations the ASA offers the practice of anesthesiology, an invaluable bridge between science and clinical practice.     

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??Updates of NCCN clinical practice guidelines for gastric cancer XU Ze-kuan.Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing210029, China
Abstract In recent years, with the rapid development of diagnosis and treatment of gastric cancer, NCCN gastric cancer clinical practice guidelines also continue to release new versions to follow up the progress of the new frontier. In the new NCCN guideline (Version1.2015), new evidence and standard were introduced, and four major aspects were revised,including: ??1??The criteria of unresectability for cure was updated, ??2??the principles of genetic risk assessment for gastric cancer, the new risk assessment and genetic consultation were modified, ??3??the systemic therapy for locally advanced, locally recurrent or metastatic gastric cancer were modified, ??4??the partial contents of radiation therapy were revised. The new guideline has included the latest research achievements, which makes the concept of the treatment of gastric cancer more scientific and standardized. It will provide important guidance for the future clinical practice.     

Review article: The role of practice guidelines and evidence-based medicine in perioperative patient safety

Purpose

The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety.

Principal findings

The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue.

Conclusions

Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.     

Quality assurance by introduction of internal medicine guidelines. What Can we learn by comparing various clinics?

It is the objective of guideline controlled quality assurance to transfer the best knowledge (evidence based medicine) into clinical practice. The best approach to make these guidelines effective is to involve the potential users (doctors/nurses) in local guideline development. An own study of benchmarking "laparoscopic gallbladder surgery" in 9 hospitals could demonstrate the enormous potential of increasing effectiveness and efficiency by guideline application, since the hospital costs differed double the price with the same result. Internal guidelines help to improve the results and reduce costs.     

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Background

Guidelines are developed to improve the quality of patient care. The effect of German urologic guidelines has not been evaluated so far. Therefore, we aimed to systematically investigate the acceptance, use, and quality of the published guidelines from a user’s perspective.

Methods

A link to an online questionnaire concerning use and barriers to the application of guidelines was distributed via e-mail by the German Society of Urology (DGU). German urologists’ opinions on differences in national guideline quality were evaluated regarding prostate cancer (PCA), bladder cancer, germ cell tumors (GCT), renal cell carcinomas, and erectile dysfunction.

Results

Four hundred sixty-seven German urologists participated. More than 90% of the participants considered guidelines to be helpful. The Internet as the main tool for guideline distribution was favored by 28.4%, followed by publication in Urologe A. The main barrier to guideline usage was attributed to the lack of up-to date clinical data. Guidelines for GCT scored best in all quality categories and reached the highest level of use (65.8%), and 40.5% of participating urologists considered the additional establishment of comprehensive care centers for GCT as more effective for quality improvement than guideline development alone. For the other urologic tumors, especially PCA, guideline development was favored as a tool for quality improvement.

Conclusion

More than 90% of participating urologists accept clinical guidelines as useful instruments in clinical practice and for therapeutic decisions. Our results should be integrated into guideline dissemination and implementation strategies in order to achieve a higher degree of treatment conformation to guidelines.     

What is the utilization of the SAGES guidelines by its members?

Background

The development and implementation of evidence-based clinical practice guidelines involves many challenges. The Society of the American Gastrointestinal and Endoscopic Surgeons (SAGES) has been at the forefront of guideline development for laparoscopic surgery since 1991, providing its membership with guidelines on the clinical application of procedures and the granting of privileges. The objective of this study was to assess the use of SAGES guidelines by its members.

Methods

An electronic survey of SAGES members was conducted via e-mail in August 2007. Members were asked if they used the guidelines, how often, for what purposes and when, and to rank the frequency of use and the usefulness of each of the 26 guidelines. They also were asked to suggest topics for new guideline development and to provide comments.

Results

Two hundred thirty-nine SAGES members (4.1%) responded to the survey; 121 (50%) responders used the guidelines. Of these, 95% accessed the guidelines monthly or less often, 58% after hours, 52% during work hours, and 9% while on call. Reasons for guideline use included developing practice protocols (56%) and patient treatment paradigms (51%), creating education and training guidelines for staff privileges (35%), and credentialing new medical staff (25%). The most often used and most useful guidelines included clinical application guidelines on laparoscopic bariatric, antireflux, biliary, and colorectal surgery, laparoscopic appendectomy, and deep vein thrombosis prophylaxis. Some respondents indicated no knowledge of guideline existence and made requests for new guidelines.

Conclusions

The results of this survey provided valuable information about current use of SAGES guidelines by its members. The pattern of use highlights the need for interventions that increase member awareness and adoption of these guidelines. Such efforts are currently underway.     

Reihe Evidenzbasierte Chirurgie

Systematic reviews and meta-analyses represent essential elements of surgical practice and research. They provide the highest possible evidence level and enable busy surgeons to rapidly gain a comprehensive overview about an important clinical question. Moreover, they constitute a foundation for evidence-based surgical clinical practice, treatment guidelines, knowledge transfer, and research prioritization. However, the quality of systematic reviews varies depending on the quality of the included studies and their methodological rigour. Therefore, surgeons need basic skills to critically read and appraise such meta-analyses and systematic reviews. The objective of this educational review is to provide surgeons with essential skills to understand and judge the quality of systematic reviews as well as their applicability to their own surgical practice.     

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??Six fundamental questions on external beam radiation therapy for HCC ZENG Shao-chong. Department of Radiology??Zhongshan Hospital??Fudan University??Shanghai 200032??China
Abstract NCCN guideline for hepatocellular carcinoma (HCC) has suggested that all tumors irrespective of the location may be amenable to external beam radiotherapy (EBRT). In their guideline??some Asian countries have recommended that HCC patients receive EBRT. When a physician proposes administering radiation therapy to a HCC patient??six fundamental questions must be answered. Understanding the questions is crucial for radiation oncologists. The questions include that profit, aim, target area, dose, technique of radiotherapy and whether need to combine other treatment methods or not.     

Stellenwert ärztlicher Leitlinien in der Arzthaftungsbegutachtung

The medico-legal status of clinical practice guidelines is a frequently raised question. Since guidelines are not issued by legislative bodies, they are not legal rules. However, they may have or acquire legal significance, for instance when they are applied by a court as auxiliary standards to decide a case of professional misconduct or malpractice. However guidelines are not likely to be used as the sole basis for evaluating negligence, and in many jurisdictions, they may not even be seen as having a special status in law. Usually the perceived value of guidelines in a court will be conditional on several factors, in particular the extent to which they are based on scientific evidence, reflect a consensus among peers, and are issued by a group or institution with authority. Basically, guidelines will not provide definite answers even when they do not allow for much flexibility in application. A particular course of action must be judged in the light of the specific health problem and the specific circumstances of a given patient. Sometimes, there can be competing guidelines, for instance developed in different hospitals or regions in other cases, expert testimony may be used in a court to challenge the authority of a guideline. For all these reasons, the courts will not automatically equate compliance with guidelines with good medical practice. Mere deviation from a guideline is unlikely to be considered as negligent, unless the practice concerned is so well established that no responsible doctor would fail to adhere to it.     

Factors influencing hospital implementation of acute pain management practice guidelines.

STUDY OBJECTIVE: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. DESIGN: Two questionnaire surveys. SETTING: Healthcare Association of New York State, Albany, NY. MEASUREMENT: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage. MAIN RESULTS: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. CONCLUSIONS: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.     

绝经后骨质疏松症中医临床实践指南编制要点解读

为了使指南使用者了解绝经后骨质疏松症中医临床实践指南的编制过程,笔者针对编制过程中的要点问题予以解读。主要包括4项内容,分别是临床问题/结局指标的收集与遴选、证据获取、证据质量评价、推荐意见形成。其中,临床问题的收集与遴选分为3轮,第一轮是广泛收集本指南需要解决的临床问题,第二轮是对第一轮收集的临床问题进行重要性评分,第三轮是通过共识会议法,最终确定19个临床问题及结局指标。证据获取方面,首先检索中英文数据库,然后进行文献的合并与查重,文献的初筛,文献的分类、再筛选,最终纳入系统评价1篇,随机对照研究114篇。证据质量评价及推荐意见形成均按照GRADE原则完成。推荐意见形成过程中,需要注意虽然中医药文献的证据质量普遍偏低,但并不等于中药本身的疗效不佳。需要专家结合临床经验进行全面评估,形成推荐意见。本编制要点解读可使绝经后骨质疏松症中医临床实践指南的制定更加公开透明,并为今后中医临床实践指南的制定提供参考。     

晚期癌症患者预后沟通策略的证据总结

目的 评价并总结晚期癌症患者预后沟通策略的最佳证据，为临床实践提供参考。 方法 根据“6S”证据模型，检索晚期癌症患者预后沟通相关的所有证据，包括临床指南、临床决策、专家共识、系统评价。评价纳入文献的质量，进行证据的归纳与总结。 结果 共纳入7篇文献，其中1篇临床决策、2篇指南、4篇系统评价，汇总了沟通前评估、沟通前准备、沟通时技巧、促进希望的方式、提高沟通能力共5个方面19条证据。 结论 晚期癌症患者预后沟通策略最佳证据可为临床相关人员与晚期癌症患者进行良好的预后沟通提供参考。但在证据转化时需进行本土化决策，以提高晚期癌症患者生活质量。     

Evidence-based clinical practice guidelines for prostate cancer: the need for a unified approach

PURPOSE OF REVIEW: Clinical practice guidelines are being increasingly recognized as critically important to an evidence-based practice. This article reviews the different approaches used by leading urological organizations to the development of prostate cancer guidelines. It further introduces the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group as a unified approach to guideline development. RECENT FINDINGS: Clinical guidelines on the management of prostate cancer demonstrate major methodological differences. Most notably, considerable discrepancies with regards to the systems used to grade the quality of the evidence and the strength of recommendation exist. The GRADE approach classifies the quality of evidence as high, moderate, low or very low, according to factors that include study design and execution, and the consistency of the results. It subsequently classifies recommendations as strong or weak, according to the balance between benefits and downsides and the degree of confidence in estimates of the downsides. SUMMARY: There is an urgent need to standardize processes used to develop clinical guidelines for the management of patients with prostate cancer by leading urological organizations. Adoption of the GRADE approach would offer considerable rewards in terms of efficiency, guideline credibility and optimal clinical decision-making.     

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??Standardization practice of multi-disciplinary comprehensive treatment for colorectal cancer WANG Xi-shan. Department of Colorectal Surgery, the Tumour Hospital of Harbin Medical University, Harbin150080, China
Abstract Colorectal cancer??CRC) ranks the third place of common cancer diseases in the world. In China, CRC incidence rate is increasing year after year with about 400 000 new patients every year. So far, CRC is on the second place of the digestive system tumor diseases in China. Multi-disciplinary comprehensive treatment has become the main treatment modalities of CRC. It is the science of evidence-based medicine and emphasized standardization and individualized treatment. It is providing the best clinical treatment to patients. At present, Chinese oncosurgery still faces a number of specialist problems,which should be solved urgently, need a strict rules-based system. The system should be based on the patients’specific circumstances,such as cancer characteristics, pathological and biological characteristics, and also must take into account the economic situation of patients with a planned and rational application of existing treatment. It should be developed a set of guidelines of Chinese patients with the overall standardization of treatment programs and a view to improve the cure rate and patient quality of life.     

Translation of benign prostatic hyperplasia guidelines into clinical practice

PURPOSE OF REVIEW: The aim of this article is to describe the current position of clinical practice guidelines for benign prostatic hyperplasia in daily management and identify the potential barriers that may hinder the implementation of guidelines into clinical practice. RECENT FINDINGS: Recent studies have attempted to compare and grade benign prostatic hyperplasia clinical practice guidelines using appraisal instruments underlining the issues of quality and updates of guidelines. Surveys have evaluated the adoption of guidelines from the urological community and recent studies have made major contributions to our knowledge of the translation of evidence to daily practice. SUMMARY: Numerous clinical practice guidelines (both national and international) for benign prostatic hyperplasia exist. High methodological quality clinical practice guidelines are likely to be the most beneficial to patients and strength of recommendations depends on available evidence. Efforts to implement guidelines are not always successful and a considerable variation especially in diagnostic assessment of benign prostatic hyperplasia has been reported. Difficulties in translation of benign prostatic hyperplasia guidelines into clinical practice are related to lack of knowledge but also to differences in routine practices, beliefs, cost, availability, and reimbursement policy. Bridging the implementation gap represents a challenging task for clinical practice guideline supporters.