Levels of evidence and grades of recommendation supporting European society for medical oncology clinical practice guidelines

Background:The European Society for Medical Oncology(ESMO)guidelines are among the most comprehensive and widely used clinical practice guidelines(CPGs)globally.However,the level of scientific evidence supporting ESMO CPG recommendations has not been systematically investigated.This study assessed ESMO CPG levels of evidence(LOE)and grades of recommendations(GOR),as well as their trends over time across various cancer settings.Methods:We manually extracted every recommendation with the Infectious Diseases Society of America(IDSA)classification from each CPG.We examined the distribution of LOE and GOR in all available ESMO CPG guidelines across different topics and cancer types.Results:Among the 1,823 recommendations in the current CPG,30%were classified as LOEⅠ,and 43%were classified as GOR A.Overall,there was a slight decrease in LOEⅠ(−2%)and an increase in the proportion of GOR A(+1%)in the current CPG compared to previous versions.The proportion of GOR A recommendations based on higher levels of evidence such as randomized trials(LOEⅠ–Ⅱ)shows a decrease(71%vs.63%,p=0.009)while recommendations based on lower levels of evidence(LOEⅢ–Ⅴ)show an increase(29%vs.37%,p=0.01)between previous and current version.In the current versions,the highest proportion of LOEⅠ(42%)was found in recommendations related to pharmacotherapy,while the highest proportion of GOR A recommendations was found in the areas of pathology(50%)and diagnostic(50%)recommendations.Significant variability in LOEⅠand GOR A recommendations and their changes over time was observed across different cancer types.Conclusion:One-third of the current ESMO CPG recommendations are supported by the highest level of evidence.More well-designed randomized clinical trials are needed to increase the proportion of LOEⅠand GOR A recommendations,ultimately leading to improved outcomes for cancer patients.

Research on the development methodology for clinical practice guidelines for organic integration of traditional Chinese medicine and Western medicine

Integrated traditional Chinese medicine(TCM)and Western medicine(WM)is a new medical science grounded in the knowledge bases of both TCM and WM,which then forms a unique modern medical system in China.Integrated TCM and WM has a long history in China,and has made important achievements in the process of clinical diagnosis and treatment.However,the methodological defects in currently published clinical practice guidelines(CPGs)limit its development.The organic integration of TCM and WM is a deeper integration of TCM and WM.To realize the progression of"integration"to"organic integration",a targeted and standardized guideline development methodology is needed.Therefore,the purpose of this study is to establish a standardized development procedure for clinical practice guidelines for the organic integration of TCM and WM to promote the systematic integration of TCM and WM research results into clinical practice guidelines in order to achieve optimal results as the whole is greater than the sum of the parts.

Chinese version of NCCN Clinical Practice Guidelines in Oncology officially authorized by NCCN

The publishing conference of the Chinese version of National Comprehensive Cancer Network （NCCN） Clinical Practice Guidelines in Oncology （hereinafter referred to as NCCN Guidelines） and the inaugural peer reviewer meeting of NCCN Clinical Practice Guidelines in Oncology： Digestive System Cancers （hereinafter referred to as NCCN Guidelines on Digestive System Cancers） were held in People＇s Medical Publishing House in January 28^th, 2016 （Figure 1）.

On Treatment Patterns for Modeling Medical Treatment Processes in Clinical Practice Guidelines

Clinical practice guidelines(CPGs)contain evidence-based and economically reasonable medical treatment processes.Executable medical treatment processes in healthcare information systems can assist the treatment processes.To this end,business process modeling technologies have been exploited to model medical treatment processes.However,medical treatment processes are usually flexible and knowledge-intensive.To reduce the effort in modeling,we summarize several treatment patterns(i.e.,frequent behaviors in medical treatment processes in CPGs),and represent them by three process modeling languages(i.e.,BPMN,DMN,and CMMN).Based on the summarized treatment patterns,we propose a pattern-based integrated framework for modeling medical treatment processes.A modeling platform is implemented to support the use of treatment patterns,by which the feasibility of our approach is validated.An empirical analysis is discussed based on the coverage rates of treatment patterns.Feedback from interviewed physicians in a Chinese hospital shows that executable medical treatment processes of CPGs provide a convenient way to obtain guidance,thus assisting daily work for medical workers.

An Analysis of the Application of the Suggestions of Clinical Practice Guideline for Ostomy Care in China:A Cross-Sectional Investigation

Background:Clinical practice guidelines refer to the guidance provided by the expert system to help medical staff and patients decide on appropriate treatments for a specific clinical situation,mainly including guidelines based on expert consensus and evidence-based guidelines.Since there is no research and clinical application of a specific stoma guidance in China.It is of great significance to understand the application status of the recommended guidelines and the influencing factors in promoting the development of stoma care.Purpose:To investigate the application status of recommended clinical practice guidelines for stoma nursing in China,and to analyse the reasons for the knowledge and application of recommendations.Methods:The Questionnaire on the Application of Recommendations in Clinical Practice Guidelines for Ostomy Nursing was adopted.Results:We collected 195 questionnaires and 183 valid questionnaires were available.(1)The average knowledge rate of a total of 31 recommendations was 73.65%.The main reasons for unknown were insufficient dissemination and lack of training.(2)The average application rate of the 31 recommendations was 58.08%.The overall satisfaction rate of people who used them was high.The main reasons for not applying recommendations were complex.Conclusions:Different levels of recommendations awareness and application are different.There is a lack of evidence-based guidelines for clinical practice in ostomy nursing in the field of stoma care in China,which limits the scientific development of stoma care to a certain extent.However,this study provides reference for the future construction of a guidebook adapted to our country’s localization.

Colorectal surgeon consensus with diverticulitis clinical practice guidelines

AIM To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand.METHODS A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios.RESULTS The response rate was 102(50%). For 19 guidelinebased scenarios, only 11(58%) reached consensus(defined as > 70% majority opinion) and agreed with guidelines; while 3(16%) reached consensus and did not agree with guidelines. The remaining 5(26%) scenarios showed community equipoise(defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failureof conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based(Fisher's exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis(79% vs 41%, P < 0.0001).CONCLUSION While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.

Adherence to Clinical Practice Guidelines during Antenatal Management of Gestational Diabetes Mellitus: An Integrative Review

The number of pregnant women affected by gestational Diabetes (GDM) is increasing globally with an estimated prevalence as high as 15%. Gestational Diabetes Miletus is associated with birth complications for women and newborn, includes development of type II diabetes, preeclampsia during pregnancy, increasing the risk of fetal loss, stillbirth and perinatal death. An integrative literature review applied, systematic search from different data base obtained from international and middle east countries to assess adherence level of guidelines. Clinical guidelines are set to ensure and assure homogeneity as well as the quality of provision of care. National and international consensus has yet to be achieved in the management of diabetes in pregnancy, adherence of recommended antenatal care content to a minimum level appears to be unmet. Complete provider adherence to first antenatal guidelines was 48.1%, Guideline dissemination alone does not change practice;assessment of barriers/enablers and implementation is important. Guidelines are useless when they are not used or adhered to. Each guideline needs an Appendix on how adherence has to be measured, there is a need for some uniformity across guidelines to measure adherence. Diabetes management is an essential constituent to prevent prognosis of diabetes complications.

Characteristics and quality of clinical practice guidelines for diabetic kidney disease:a systematic review

OBJECTIVE:To assess the quality of Clinical practice guidelines(CPGs)in the context of diabetic kidney disease(DKD)and determine whether any factors affect the quality.METHODS:We searched eight databases along with five international and national organizations to develop or archive guidelines from their inception to July 2023,with an additional search of medlive.cn.And the authoritative organizations related to nephrology.CPGs and consensus statements created using direct differential diagnosis or therapy for DKD were included without language restrictions.Their quality was evaluated by four reviewers using the Appraisal of Guidelines for Research and EvaluationⅡ(AGREEⅡ)instrument.Along with the item and domain scores,the guideline was also allocated an overall quality score,which ranged from 1(lowest possible quality)to 7(highest possible quality).Moreover,an overall recommendation for use was also assigned(“recommended”,“recommended with modifications”or“not recommended”).RESULTS:A total of 16 CPGs were included,of which 14 were from Asia and the remaining two from Europe.These two CPGs were updated in the third version.Six CPGs were recommended for use because their primary domains scored in the medium or high category.Furthermore,five CPGs were recommended with modifications as the stakeholder involvement,applicability,and editorial independence domains were evaluated as low categories.In all domains,the lowest average score was for rigour of development(33%),followed by application(36%),and stakeholder involvement(51%).The highest average score was for scope and purpose(79%),followed by clarity of presentation(75%).None of the CPGs considered the patient's viewpoint,and six of 16 CPGs did not use any grading system to translate the evidence into recommendations.Additionally,only three of 16 CPGs shared search strategy,and eight of 16 CPGs did not declare a funding source.CONCLUSIONS:According to the AGREE II evaluation,more than one in four CPGs for DKD had poor methodological quality.Enhanced efforts are needed to advance the rigour of development,application,and editorial independence of DKD guideline panels for most guidelines.Stakeholders,CPG developers,and CPG users should consider methodological quality while choosing CPGs,and interpret and implement their issued suggestions.

Organic Integration of Traditional Chinese and Western Medicines—Future of Clinical Practice Guidelines of Integrated Traditional Chinese and Western Medicines

The transformation and implementation of clinical practice guidelines for integrated traditional Chinese medicine(TCM)and Western medicine(WM)is crucial to the adoption of medical science and technological findings and is an important way for TCM to be made available to the world.First,clinical practice guidelines(CPGs)of TCM and WM integration in recent years was analyzed to clarify the current situation and problems in the existing guidelines according to the following four perspectives:(1)perspective of TCM and WM integration in guidelines,(2)diagnosis Using integrated TCM and WM,(3)integration of TCM and WM treatment,(4)promoting TCM and WM integration.Secondly,the information and quality evaluation of CPGs for integrated Chinese and Western medicine in 2020–2022 were analyzed to explore the degree and methods of integration of Chinese and Western medicine guidelines.And last this study aimed to lay a foundation for the further establishment of Chinese characteristic,repeatable,and calculable clinical practice guidelines of TCM and WM integration.

World Federation of Acupuncture-Moxibustion Societies Clinical Practice Guideline on Acupuncture-Moxibustion:Non-Specific Low Back Pain recommendation summaries

Clinical Practice Guideline on Acupuncture and Moxibustion:Nonspecific low back pain was revised and released by the Standards Working Committee of World Federation of Acupuncture-Moxibustion Societies(WFAS)on October 9,2023.This is the first clinical practice guideline(CPG)on acupuncture and moxibustion for nonspecific low back pain approved by an international academic organization,which provides the evidence-based recommendations and practical therapeutic protocols for international acupuncture practitioners.This CPG was developed by following Grades of Recommendation,Assessment,Development,and Evaluation(GRADE)methodology,and the Principles of the World Health Organization Handbook for Guideline Development.The guideline development group(GDG)from different countries,with different professions,played a critical role in the formulation of clinical questions,recommendations,and therapeutic protocols.Recommendations are the key content of a CPG and the direct answers to clinical questions.Hence,this article focuses on the recommendations of this CPG.The recommendations were formulated using the modified Delphi method and the GRADE grid rules,based on the updated systematic reviews of clinical evidence.A total of seven recommendations for ten clinical questions were formulated in this CPG,including one conditional recommendation for either the intervention or the comparison based on very low quality of evidence,and six conditional recommendations for the intervention based on very low quality of evidence.

2023 Chinese national clinical practice guideline on diagnosis and management of ulcerative colitis

The role of Chinese expert consensus in standardization and improvement of the clinical diagnosis and treatment of inflammatory bowel disease(IBD)is self-evident.As clinical and basic research in China becomes standardized under a better understanding of IBD,more data on Chinese patients have become available to develop a consensus and guideline.This guideline,collaboratively developed by the IBD Group,Chinese Society of Gastroenterology,incorporates the latest international consensus statements,[1-7]domestic research findings,and practical considerations,as an update based on the 2018 Chinese consensus on IBD management.[8]The IBD guideline consists of two parts:ulcerative colitis(UC)and Crohn’s disease,and this manuscript presented the UC part.The evidence used in this guideline was collected and analyzed by the standard of guideline,and the contents were organized as problem statements,for clarity.The formulation of this guideline aimed to reflect the latest progress in IBD,providing comprehensive and valuable guidance for the clinical management of IBD.

A Protocol for Developing Chinese Clinical Practice Guidelines of Hypertension

To improve the standard screening, diagnosis, and treatment of hypertension in patients in China;realize the standardization of clinical practice of hypertension;and improve the prevention and control level of hypertension in China, it is both important and necessary to develop a clinical practice guideline for hypertension according to a recognized methodology. Jointly sponsored by the National Center for Cardiovascular Diseases, Chinese Medical Doctor Association, Hypertension Committee of the Chinese Medical Doctor Association, Chinese Society of Cardiology, and Hypertension Committee of Cross-Straits Medicine Exchange Association, the “Chinese Clinical Practice Guidelines of Hypertension” was proposed. Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences, Guideline and Standards Research Centre of Chinese Medical Association Publishing House, Lanzhou University Institute of Health Data Science, and Lanzhou University GRADE Center will provide methodological support for the guidelines.

Virtual reality:The bridge between medical education and clinical practice

After perusing the paper by Kim et al,I discovered that this is an interesting manuscript and a successful study.Virtual reality(VR)is an emerging and promising technology employed in the domain of medical practice and medical education over the past decade.In the era of big data,VR is constantly progressing in the fields of medical education and clinical diagnosis and treatment.As a novel scientific and technological tool,VR not only overcomes multiple limitations of the traditional medical teaching mode but also reduces the reliance on personnel and equipment.VR can simulate the real clinical situation,stimulate the enthusiasm of young doctors and nurses for clinical study,and simultaneously safeguard and promote medical safety and doctor-patient harmony.Favorable outcomes have been attained in clinical teaching and diagnosis and treatment activities.While enhancing the training conditions of medical cosmetics and elevating the level of clinical practice and teaching,the risks resulting from improper clinical diagnosis and treatment have been circumvented.All of this is evident and comprehensible.

Machine learning applications in healthcare clinical practice and research

Machine learning(ML)is a type of artificial intelligence that assists computers in the acquisition of knowledge through data analysis,thus creating machines that can complete tasks otherwise requiring human intelligence.Among its various applications,it has proven groundbreaking in healthcare as well,both in clinical practice and research.In this editorial,we succinctly introduce ML applications and present a study,featured in the latest issue of the World Journal of Clinical Cases.The authors of this study conducted an analysis using both multiple linear regression(MLR)and ML methods to investigate the significant factors that may impact the estimated glomerular filtration rate in healthy women with and without non-alcoholic fatty liver disease(NAFLD).Their results implicated age as the most important determining factor in both groups,followed by lactic dehydrogenase,uric acid,forced expiratory volume in one second,and albumin.In addition,for the NAFLD-group,the 5th and 6th most important impact factors were thyroid-stimulating hormone and systolic blood pressure,as compared to plasma calcium and body fat for the NAFLD+group.However,the study's distinctive contribution lies in its adoption of ML methodologies,showcasing their superiority over traditional statistical approaches(herein MLR),thereby highlighting the potential of ML to represent an invaluable advanced adjunct tool in clinical practice and research.

Diagnosis and Management of Biliary Strictures after Deceased-Donor Liver Transplantation Based on Clinical Practice

Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.

Trust in Clinical Practice: A Systematic Review

Background: The aim of this study is to gain a better understanding of the true importance of trust in clinical practice by looking at how it is formed, how it affects clinical practice, and how to improve it. Methods: Using the PRISMA-ScR checklist, a review of the literature was performed to identify research evaluating the importance of trust in the doctor-patient relationship. After thorough screening and removal of duplicates, 21 articles were used in the literature review. Results: The classifying themes that emerged in the selected articles were What Makes Trust and Effects of Trust. The theme of What Makes Trust garnered two subthemes as well: Impact of Doctor-Patient Relationship on Trust and Impact of Shared Decision-Making on Trust. Further to that, the overarching themes found were slightly more specific. They were Traits of Trust, Mistrust and Barriers to Trust, Positive Effects of Trust and the Effects of a Lack of Trust. We found that the best way to improve trust was to improve communication between the patient and the doctor. Additionally, we found that the biggest barrier to a trusting doctor patient relationship was a stigmatised condition, followed by a perception of a financially-motivated doctor. Finally, we found that a lack of trust can prevent patients from seeking and receiving proper treatment. Conclusions: With a better understanding of how trust is built and the extent of the role it plays in clinical practice, we hope that this growing knowledge can improve the practice of many doctors in the future. It is certain that more research needs to be done in this area, especially focusing on vulnerable and stigmatised populations such as chronic pain patients.

Clinical practice guidelines for the interventional treatment of advanced pancreatic cancer(5^(th)edition)

Pancreatic cancer has become a major disease affecting people’s health because of its insidiousness,rapid progression and poor prognosis.Based on the practical needs of clinical work,combined with domestic multi-center research and experience,this guideline provides constructive suggestions for the interventional treatment of pancreatic cancer.

Perception of Male Nursing Students about Their Maternity Clinical Practice: A Cross-Sectional Survey from a Nursing College

The aim of this study was to explore the perception of male nursing students’ experiences and challenges in maternity clinical practice. A quantitative cross-sectional survey design was used. The self-administered questionnaire included 18 items 5-point Likert scale to identify the challenges experienced by male nursing students in their maternity clinical practice, and 14 items to assess comfort level in performing procedures in maternity clinical areas. Participants were 93 male nursing students who had completed their maternity clinical posting in different maternity clinical areas as a part of their nursing program, at the College of Nursing, Kuwait. Results showed that male nursing students are not very keen on undergoing maternity clinical training (Chi-square analysis χ2 = 96.939;P χ2 = 108.638;P χ2 = 5.297;P = 0.021). In conclusion, this study showed that being treated differently and being refused to provide care to clients were the main challenges faced by male nursing students during their maternity practice. The participants had a strong belief that they will not be accepted by maternity clients because of the gender difference and cultural influence. There is a need to design strategies in both academic and clinical settings to overcome barriers to male nursing students’ engagement in the various maternity care areas. Our findings also indicate the need to embrace gender diversity in maternity clinical practice and call for professionalism, gender and cultural awareness creation, and advocacy.

Study on good clinical practices among researchers in a tertiary healthcare institute in India

BACKGROUND Good clinical practice(GCP)is put in place to protect human participants in clinical trials as well as to ensure the quality of research.Non-adherence to these guidelines can produce research that may not meet the standards set by the scientific community.Therefore,it must be ensured that researchers are wellversed in the GCP.But not much is known about the knowledge and practices of the GCP in the medical colleges of North India.AIM To assess the knowledge and practices of researchers about GCP and analyze these with respect to the demographics of participants.METHODS This is a cross-sectional study.A self-structured questionnaire about GCP,after expert validations,was circulated among researchers,at a tertiary healthcare institute,All India Institute of Medical Sciences(AIIMS),Rishikesh.A total of 59 individuals,who were selected by universal sampling,participated in the study.All healthcare workers who have been investigators of Institutional Ethics Committee-approved research projects,except residents and faculty,and are still a part of the institute have been included in the study.The study was approved by the Institutional Ethics Committee of AIIMS,Rishikesh.We used descriptive analysis and the Chi-squared test to analyze data.P value<0.05 was considered significant.RESULTS Out of 59 participants,only 11(18.6%)were certified for GCP.Most of the participants(64.4%)had“Average”knowledge,33.9%had“Good”knowledge and 1.7%had“Poor”knowledge.Only 49%of participants had satisfactory practices related to GCP.There was a significant difference in the knowledge based on the current academic position for the items assessing knowledge of institutional review board(P=0.010),confidentiality&privacy(P=0.011),and participant safety&adverse events(P<0.001).There was also a significant difference in knowledge of research misconduct(P=0.024)and participant safety&adverse events(P=0.011)based on certification of GCP.There was a notable difference in the practices related to recruitment&retention on the basis of current academic position(P<0.001)and certification of GCP(P=0.023).We also observed a considerable difference between the knowledge and practices of GCP among the participants(P=0.013).CONCLUSION Participants have basic knowledge of GCP but show a lack thereof in certain domains of GCP.This can be addressed by holding training sessions focusing on these particular domains.

Development of the Scientific,Transparent and Applicable Rankings (STAR) tool for clinical practice guidelines

Background:This study aimed to develop a comprehensive instrument for evaluating and ranking clinical practice guidelines,named Scientific,Transparent and Applicable Rankings tool(STAR),and test its reliability,validity,and usability.Methods:This study set up a multidisciplinary working group including guideline methodologists,statisticians,journal editors,clinicians,and other experts.Scoping review,Delphi methods,and hierarchical analysis were used to develop the STAR tool.We evaluated the instrument’s intrinsic and interrater reliability,content and criterion validity,and usability.Results:STAR contained 39 items grouped into 11 domains.The mean intrinsic reliability of the domains,indicated by Cronbach’sαcoefficient,was 0.588(95%confidence interval[CI]:0.414,0.762).Interrater reliability as assessed with Cohen’s kappa coefficient was 0.774(95%CI:0.740,0.807)for methodological evaluators and 0.618(95%CI:0.587,0.648)for clinical evaluators.The overall content validity index was 0.905.Pearson’s r correlation for criterion validity was 0.885(95%CI:0.804,0.932).The mean usability score of the items was 4.6 and the median time spent to evaluate each guideline was 20 min.Conclusion:The instrument performed well in terms of reliability,validity,and efficiency,and can be used for comprehensively evaluating and ranking guidelines.