Management of regional citrate anticoagulation for continuous renal replacement therapy:guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy(CRRT)is widely used for treating critically-ill patients in the emergency department in China.Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT.Regional citrate anticoagulation(RCA)has been shown to potentially be safer and more effective,and is now recommended as the preferred anticoagulant method for CRRT.However,there is still a lack of unified standards for RCA management in the world,and there are many problems in using this method in clinical practice.The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association(CMDA)organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues,including the advantages and disadvantages of RCA in CRRT anticoagulation,the principle of RCA,parameter settings for RCA,monitoring of RCA(mainly metabolic acid-base disorders),and special issues during RCA.Based on the latest available research evidence as well as the paneled experts'clinical experience,considering the generalizability,suitability,and potential resource utilization,while also balancing clinical advantages and disadvantages,a total of 16 guideline recommendations were formed from the experts'consensus.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection(RLR)has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system,however,controversies still exist.Based on the foundation of the previous consensus statement,this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice.The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine(EBM).Relevant literature was reviewed and analyzed by the evidence evaluation group.According to the WHO Handbook for Guideline Development,the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022,a total of 14 recommendations were generated.Among them were 8 recommendations formulated by the GRADE method,and the remaining 6 recommendations were formulated based on literature review and experts’opinion due to insufficient EBM results.This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time.Advantages of ports include a simple nursing process,low risk of infection and embolism,and high patient comfort.In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications,the Chinese Research Hospital Association Digestive Tumor Committee,the Chinese Association of Upper Gastrointestinal Surgeons,the Chinese Gastric Cancer Association,and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nationwide expert letter reviews and on-site seminars,and formulated an expert consensus of the operation guidelines.

Does High Systolic Blood Pressure Truly Increase Medical Expenditure?—An Empirical Analysis of the New 2017 ACC/AHA Hypertension Guideline

Background: High blood pressure (BP) or hypertension is considered one of the top global disease burden risk factors. In November 2017, the ACC/AHA and other organizations announced a new hypertension guideline of 130/80 mmHg. Data and Methods: We evaluate the effects of BP on increases in medical expenditures using transformation tobit models and a dataset containing 175,123 medical checkups and 6,312,125 receipts from 88,211 individuals in three health insurance societies. The sample period was April 2013 to March 2016. We first created a database of combined checkup results and medical expenditures. The power transformation tobit model was then used to remove the effects of other variables, and we investigated the relation between medical expenditures and BP, especially systolic BP (SBP). Results: We observed negative effects of SBP on medical expenditures. The results raise uncertainty about the reliability of the new guideline, at least for SBP. Although the simple correlation coefficient of medical expenditures and SBP was positive, the sign of the SBP estimate became negative when a variable representing obesity was included. In terms of other medical checkup items, while LDL is considered the “bad” cholesterol, it reduced medical expenditures. Conclusion: Our results did not support the new 2017 ACC/AHA guideline for SBP. A wide and careful range of reviews not only for heart diseases but also for other disease types will be absolutely necessary. New studies to verify the guideline should also be conducted. Limitations: The dataset was observatory, the sample period only 3 years, and we could not complete a time-series analysis of individuals.

Empirical Studies of Effects of High Blood Pressure on Medical Costs and Heart Disease: Is the 2017 ACC/AHA Guideline Supported by Enough Evidence?

Background: The American College of Cardiology (ACC), American Heart Association (AHA) and other organizations announced a new hypertension guideline in November 2017. However, previous studies have pointed out that this new guideline might lack sufficient evidence to justify its use. Data and Methods: The effects of blood pressure (BP) on medical costs and on the probability of having heart disease as anamnesis are analyzed. We used a dataset containing 175,123 medical checkups and 6,312,125 receipts from 88,211 individuals obtained from three health insurance societies from April 2013 to March 2016. The dataset was divided into subgroups based on whether the patients had diabetes and took hypertension medications. The power transformation and probit models were used in the study. Results: We observed negative effects of systolic BP (SBP) on medical costs in most subgroups. We could not find evidence that higher SBP made the medical costs and probability of having heart diseases higher. The results raise uncertainty about the reliability of the new guideline, at least for SBP. Conclusion: The results of this study did not support the new 2017 ACC/AHA guideline, at least for SBP. The new guideline must be more carefully reevaluated by additional studies. Limitations: The dataset was observatory, the sample period was only 3 years, and we could not complete a time-series analysis of individuals.

2016 Chinese expert consensus and guidelines for the diagnosis and treatment of papillary thyroid microcarcinoma

The incidence of papillary thyroid carcinoma(PTC)has exponentially increased in recent years.Papillary thyroid microcarcinoma(PTMC)accounts for the majority of the reported cases of PTC.The debates and crucial issues in PTMC management have received researchers'attention.To further improve the clinical management of PTMC in China,

The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?

Background: Venous thromboembolism (VTE) is a common complication seen during or after hospitalization that manifests as deep venous thrombosis (DVT) and/or pulmonary embolism (PE). PE is considered the commonest preventable cause of death during and/or after hospitalization. Thus, pharmacological and mechanical methods are used to prevent VTE in hospitalized patients. Despite the availability of guidelines for VTE prophylaxis, it is crucial to assess the adherence and adaptation of the institution to these guidelines. Purpose: This study aimed to investigate adherence to the American College of Chest Physicians (ACCP) 2012 VTE prophylaxis guidelines in hospitalized medical patients in a tertiary care hospital in the United Arab Emirates. Methods: An observational prospective design was utilized in this study. To achieve the purpose, primary and secondary end points were identified to be the core of the investigation. The primary end points were: the incidence of bleeding, VTE, and cardiovascular events. While the secondary end points were: dose and indication validity for prophylaxis, VTE and bleeding risk assessments, adverse drug events (ADE) other than bleeding, appropriate monitoring when on low molecular weight heparin (LMWH) and the presence of contraindication at the time of prescribing LMWH. Results: 16 patients (20%) out of the total 80 met one or more of the primary end points. The vast majority of patients (81.25%) developed bleeding, while VTE was seen in one case only during hospitalization. 11 patients (13.75%) received LMWH while a contraindication was present. 15 patients (18.75%) who were prescribed LMWH had an International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score of ≥7. However, 5 out of 13 patients (38.46%) who developed bleeding had a bleeding score of ≥7, and the relationship between bleeding score of ≥7 and the development of bleeding was statistically significant (p = 0.047). When investigating the doses that were utilized, 40% were prescribed an inappropriate dose. Conclusion: Various factors played a role in the inappropriateness of VTE prophylaxis such as;poor adherence to VTE guidelines, inappropriate dosing and monitoring, and not evaluating the bleeding risk. Hence, to be able to achieve effective VTE prophylaxis, these factors need to be addressed through adherence to and adaptation of the ACCP 2012 VTE prophylaxis guidelines.

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.

Development of the Guideline for HIV Testing in South Korea with Low Prevalence of HIV-1 Infection Based on the Expert Consensus

Purpose: This study was conducted to develop a guideline for HIV testing in South Korea where the HIV prevalence is very low. It is necessary to make the recommendations presented here based on the epidemiology of opportunistic infection and cancer in the community. Methods: The development of a guideline for HIV testing was conducted using literature reviews and the agreement of Korean experts for HIV patients using a two-round Delphi consensus technique. Each expert was asked to independently answer to each item related to HIV risk. Ten experts participated in the two-round survey. Results: The individual items were determined based on the following categories: high risk behavior, symptom and diseases, colo-rectal diseases, uro-genital diseases and gynecology, skin and oral diseases. The final guideline consisted of 4-scale agreement rating (strongly recommended, recommended, not routinely recommended, no recommendation for routine provision). Discussion: We have developed the guideline for HIV testing in a country where the HIV prevalence is low based on a systematic investigation and expert consensus.

Guidelines from an expert panel for the management of diabetic macular edema in the Malaysian population

AIM:To derive a Malaysia guideline and consensus as part of the Malaysia Retina Group's efforts for diagnosis,treatment,and best practices of diabetic macular edema(DME).The experts'panel suggests that the treatment algorithm to be divided into groups according to involvement the central macula.The purpose of DME therapy is to improve edema and achieve the best visual results with the least amount of treatment load.METHODS:On two different occasions,a panel of 14 retinal specialists from Malaysia,together with an external expert,responded to a questionnaire on management of DME.A consensus was sought by voting after compiling,analyzing and discussion on first-phase replies on the round table discussion.A recommendation was deemed to have attained consensus when 12 out of the 14 panellists(85%)agreed with it.RESULTS:The terms target response,adequate response,nonresponse,and inadequate response were developed when the DME patients'treatment responses were first characterized.The panelists reached agreement on a number of DME treatment-related issues,including the need to classify patients prior to treatment,firstline treatment options,the right time to switch between treatment modalities,and side effects associated with steroids.From this agreement,recommendations were derived and a treatment algorithm was created.CONCLUSION:A detail and comprehensive treatment algorithm by Malaysia Retina Group for the Malaysian population provides guidance for treatment allocation of patients with DME.

Expert consensus of Chinese Association for the Study of Pain on the application of ozone therapy in pain medicine

This consensus was compiled by first-line clinical experts in the field of pain medicine and was organized by the Chinese Association for the Study of Pain.To reach this consensus,we consulted a wide range of opinions and conducted indepth discussions on the mechanism,indications,contraindications,operational specifications and adverse reactions of ozone iatrotechnique in the treatment of pain disorders.We also referred to related previous preclinical and clinical studies published in recent years worldwide.The purpose of this consensus is to standardize the rational application of ozone iatrotechnique in pain treatment,to improve its efficacy and safety and to reduce and prevent adverse reactions and complications in this process.

A global review of acupuncture and moxibustion recommendations in guidelines/expert consensus for chemotherapy-and/or radiotherapy-induced nausea and/or vomiting

Objective:To summarize and analyze the recommendations of acupuncture and moxibustion in the global guidelines/expert consensus of chemotherapy-and/or radiotherapy-induced nausea and/or vomiting,providing a basis for the development of clinical practice guidelines on acupuncture and moxibustion for chemotherapy-and/or radiotherapy-induced nausea and/or vomiting.Methods:We systematically searched 7 comprehensive databases,7 guideline libraries and 4 websites of societies/associations.The retrieval period was from the inception to April 1,2023.Two researchers independently screened the literature,extracted data,and used the Scientific,Transparent,and Applicable Rankings(STAR)tool to evaluate the quality of guidelines/expert consensus that contained acupuncture and moxibustion recommendations,and analyzed acupuncture and moxibustion recommendations in guidelines/expert consensus and their evidence base.Results:A total of 56 guidelines/expert consensus related to the prevention and treatment of chemotherapy-and/or radiotherapy-induced nausea and/or vomiting were included,and 22 guidelines/expert consensus contained acupuncture and moxibustion recommendations,with a total of 34 recommendations on acupuncture and moxibustion(27 supports,4 neutrals,3 objections).The STAR evaluation(excluding 1 patient version of guideline)showed that none of the guidelines/expert consensus was with high quality,95.24%(20/21)with medium quality,and 4.76%(1/21)with low quality.Although there were many recommendations of acupuncture and moxibustion in the existing guidelines/expert consensus,there was great heterogeneity among the acupuncture and moxibustion treatment regimens.Moreover,most of the guidelines/expert consensus did not describe the details of acupuncture and moxibustion treatment regimens,such as acupuncture and moxibustion manipulation,acupoint selection,course and timing of treatment,which is difficult to guide the clinical practice of acupuncture and moxibustion.Conclusion:Developing clinical practice guidelines of acupuncture and moxibustion for chemotherapyand/or radiotherapy-induced nausea and/or vomiting according to the items of the STAR tool was urgent,so as to clarify the details of acupuncture and moxibustion regimens and provide standardized treatment regimens to guide the clinical practice of acupuncture and moxibustion.

Chinese consensus on management of tyrosine kinase inhibitor-associated side effects in gastrointestinal stromal tumors

Tyrosine kinase inhibitors(TKIs) have improved the overall survival of patients with gastrointestinal stromal tumors(GISTs), but their side effects can impact dose intensity and, consequently, the clinical benefit. To date, no guideline or consensus has been published on the TKI-associated adverse reactions. Therefore, the Chinese Society of Surgeons for Gastrointestinal Stromal Tumor of the Chinese Medical Doctor Association organized an expert panel discussion involving representatives from gastrointestinal surgery, medical oncology, cardiology, dermatology, nephrology, endocrinology, and ophthalmology to consider the systemic clinical symptoms, molecular and cellular mechanisms, and treatment recommendations of GISTs. Here, we present the resultant evidence-and experience-based consensus to guide the management of TKI-associated side events in clinical practice.

An expert consensus on the evaluation and treatment of acute thoracolumbar spine and spinal cord injury in China

This is an expert consensus on the evaluation and treatment of thoracolumbar spinal injury, estab- lished from February 2009 to July 2010. The expert consensus consists mainly of six parts with a total of 54 recommendations including the overview （one item）; pre-hospital care （one item）; evaluation and diagnosis （13 items）; treatment （23 items）; prevention and treatment of major com- plications （12 items）; and rehabilitation （four items）. This is the first time that Chinese experts have published a consensus on spine and spinal cord injury. The expert consensus was established based on Delphi methods, literature analysis, and clinical experiences. Each recommendation is supported by and was interpreted using multi-level evidences. The level of agreement with the rec- ommendation among the panel members was assessed as either low, moderate, or strong. Each panel member was asked to indicate his or her level of agreement on a 5-point scale, with ＂1＂ cor- respondJng to neutrality and ＂5＂ representJng maxJmum agreement. Scores were aggregated across the panel members and an arithmetic mean was calculated. This mean score was then translated into low, moderate, or strong. After all of the votes were collected and calculated, the results showed no low-level recommendations, 10 moderate-level recommendations, and 44 strong-level recom- mendations. An expert consensus was reached and was recognized by Chinese spine surgeons. Wide-scale adoption of these recommendations is urgent in the management of acute thora- columbar spine and spinal cord injury in a broader attempt to create a standard evaluation and treatment strategy for acute thoracolumbar spine and spinal cord injury in China.

Adherence to acne treatment guidelines in the military environment-a descriptive,serial cross-sectional study

Background:Acne vulgaris,a common skin disease,affects up to 80% of the population.Moderate to severe acne requires treatment with a combination of topical and oral drugs such as antibiotics,hormones and retinoids.Retinoids have many contraindications and adverse effects requiring close monitoring.The study's objectives were to describe prescribing trends in acne medication over time in a military setting,and assess physician adherence to guidelines for acne treatment,including drug precautions,clinical monitoring,and treatment progression.Methods:We conducted a descriptive,serial cross-sectional study of acne drugs prescribed in the Israel Defense Forces(IDF) in the years 2002–2007,analyzing the classes of drugs prescribed and patient characteristics.In addition,the clinical quality of the medical encounter was assessed by examining physician adherence to IDF guidelines.Results:Between 2002 and 2007,64,281 patients were treated for acne.Treatment courses generally persisted for 1–2 months.Over 70% of female patients receiving oral retinoids were not concomitantly receiving oral contraceptives.Conclusions:This study provides a unique perspective of acne treatment in a military setting,overall displaying good adherence to general guidelines.The common prescription of oral retinoids to young females without concomitant contraception is alarming.

Expert consensus of the Chinese Association for the Study of Pain on ion channel drugs for neuropathic pain

Neuropathic pain(NPP)is a kind of pain caused by disease or damage impacting the somatosensory system.Ion channel drugs are the main treatment for NPP;however,their irregular usage leads to unsatisfactory pain relief.To regulate the treatment of NPP with ion channel drugs in clinical practice,the Chinese Association for the Study of Pain organized first-line pain management experts from China to write an expert consensus as the reference for the use of ion channels drugs.Here,we reviewed the mechanism and characteristics of sodium and calcium channel drugs,and developed recommendations for the therapeutic principles and clinical practice for carbamazepine,oxcarbazepine,lidocaine,bulleyaconitine A,pregabalin,and gabapentin.We hope this guideline provides guidance to clinicians and patients on the use of ion channel drugs for the management of NPP.

Medical Chain:联盟式医疗区块链系统

医疗数据共享、防篡改、防泄漏一直是困扰医疗行业的难题.一位患者在转诊时,往往无法提供以往的就诊信息,原因在于国内各医院医疗信息大多数情况下无法共享,而仅能通过病历、检验单等极易丢失的纸质信息来实现一部分医疗信息的共享.同时,患者的医疗信息极易造成泄露,在出现医疗纠纷时所提供的医疗信息也无法保证真实性与公正性.本文设计了一个基于实用拜占庭容错算法(Practical Byzantine fault tolerance, PBFT)的联盟式医疗区块链系统,该系统是一个多节点共同维护与共享的,并且能够防止医疗数据被篡改、泄露的医疗系统,可用来解决这些医疗难题.与现有医疗区块链系统相比,本系统具有一定的优越性与较好的适用性.

Medical schools that received the PROMED (program for the encouragement of curricular changes in medical courses)—Preconditions and change process

Since the Curriculum Guidelines (CG) which were created in 2001 and PROMED (Program for the Encouragement of Curricular Changes in Medical Courses), several schools have applied for this incentive. Medical Schools (MS) have faced important changes in their curriculum throughout the years. The purpose is to verify if medical schools that received PROMED already had a historical of curricular changes. Several interviews, which were carried out with PROMED coordinators, were recorded, transcribed and analyzed according to the Bardin’s content analysis technique. Later, these interviews were later categorized into nine themes. This paper analyses the Medical School History category which encompasses three subcategories: existence of a former changing history;need to overcome the model and changing period. It is highlighted that medical schools that received PROMED had a previous changing historical which was sometimes located in anti-hegemonic niches. It is noticeable, however, that such changes were not enough to affect the comprehension of healthillness process and its consequent results. PROMED was, effectively, the reference for medical schools implementing the C.G. which represents, now, a benchmarking for all new and old schools in the country.

Adaptation of international coronavirus disease 2019 and breast cancer guidelines to local context

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic caused by severe acute respiratory syndrome coronavirus 2(a novel coronavirus),which was first identified amid an outbreak of respiratory illness cases in Wuhan,China and declared a global health emergency,is currently considered an additional challenge in the management of patients with breast cancer(BC).Cancer patients are more vulnerable to becoming infected with severe acute respiratory syndrome coronavirus 2 and are more likely to suffer additional complications that can increase mortality.Identifying those BC patients who require more urgent therapy than others in the current situation is essential.These recommendations are based on and have been adapted from those similarly published by international scientific societies for BC management.They are divided mainly by clinical stage(early,advanced),subtype[luminal,human epidermal growth factor receptor 2(HER2),triple-negative],or type of medical treatment and setting(neoadjuvant,adjuvant,metastatic).Recommendations for HER2 and triplenegative subtypes are similar,whereas in luminal subtype there are various options of management.The objective is to adapt guidelines to local context through relevant decision-makers,avoiding duplication of efforts and optimizing use or resources.We hope that these recommendations will help medical oncologists provide the best quality care to BC patients during the COVID-19 pandemic with information tailored to our healthcare system.AIM To establish and adapt recommendations from those published by international scientific societies for BC management.METHODS The Peruvian Society of Medical Oncology developed a consensus and propose here a manuscript with recommendations for oncological medical treatment of BC during the COVID-19 pandemic.The Peruvian Society of Medical Oncology invited a panel of experts and opinion leaders on BC working in major health care systems around Peru.Panel experts selected three international clinical practice guidelines(National Comprehensive Cancer Network,European Society for Medical Oncology,Spanish Foundation Research Group in Breast Cancer),considering that these are more representative in COVID-19 management.Also,the panel agreed to include at least one European and American clinical practice guideline.RESULTS Recommendations about BC management during the COVID-19 pandemic were divided mainly by clinical stage(early,advanced),subtype(luminal,HER2,triplenegative),or type of medical treatment and setting(neoadjuvant,adjuvant,metastatic).Recommendations for HER2 and triple-negative subtypes were similar between clinical practice guidelines,whereas in luminal subtype there were various options of management.One hundred twelve recommendations were reviewed,adapted,and voted.A consensus was made in order to provide best decisions of management,avoid duplication of efforts,and optimize medical resources,considering health care system reality.These recommendations are not intended to replace clinical judgment.CONCLUSION Most of recommendations are similar,mainly in high-risk subtypes(HER2,triplenegative).Certain societies adapt them to deal with different situations involving the best decision in the management of BC patients.

An evaluation of compliance and performance following the introduction of the Inter-Facility Transport Triage Guideline

BACKGROUND：In Hong Kong, the reorganization of healthcare frame work for better utilization of resources has led to an increase in the frequency of inter-facility transport in recent years. An Inter-Facility Transport Triage Guideline （IFTTG） was introduced and evaluated on its compliance and performance. This study aimed to evaluate the compliance to the IFTTG and performance of inter-facility transport after the IFTTG was implemented. METHODS： The patients who required emergency IFT with accompanying personnel in two consecutive periods （pre-implementation period： January 1,2006 to April 30, 2006; post-implementation period： May 1,2006 to August 31,2006） were included. The compliance to pre-transport triage and transport team configuration was evaluated by a review panel with eight performance indicators identified. The performance indicators were compared individually and as an overall score. RESULTS：Sixty-eight （26 in the pre-implementation period and 42 in the post-implementation period） IFTs were reviewed. There was demonstrable improvement on compliance to the IFTTG. The appropriateness of pre-transport triage increased from 34.6% to 54.8% whereas appropriateness of transport team configuration rose significantly from 73.1% to 92.9% （P〈0.05）. Staff performance on individual IFT performance indicator was satisfactory in both periods and the means of overall score on performance indicators were 7.12 and 7.29 respectively. The most improved performance indicator was the appropriateness of transport team configuration. CONCLUSIONS： The compliance and performance with the newly implemented IFTTG were satisfactory. However, staff comment and satisfaction with the use of the new guideline should be collected so as to achieve continuous quality improvement.