[Evidence of Physical Training Programs for Fall Prevention in Seniors]. / Evidenz körperlicher Trainings-programme zur Sturzprävention bei älteren Menschen.

Evidence of Physical Training Programs for Fall Prevention in Seniors Abstract. It has been shown that physical exercise reduced fall risk by 23-42% in community-dwelling adults aged 65+. This is particularly true for physical exercises with functional, balance and strength components. Growing evidence shows that functional training is particularly effective in reducing fall risk. Functional training is composed by exercises which reflect activities of daily life, supported by weights and other aids.

[Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise]. / Guidelines 2.0: Systematische Entwicklung einer umfassenden Checkliste für eine vertrauenswürdige Leitlinienentwicklung.

BACKGROUND: Although several tools to evaluate the credibility of health care guidelines exist, guidance on practical steps for developing guidelines is lacking. We systematically compiled a comprehensive checklist of items linked to relevant resources and tools that guideline developers could consider, without the expectation that every guideline would address each item. METHODS: We searched data sources, including manuals of international guideline developers, literature on guidelines for guidelines (with a focus on methodology reports from international and national agencies, and professional societies) and recent articles providing systematic guidance. We reviewed these sources in duplicate, extracted items for the checklist using a sensitive approach and developed overarching topics relevant to guidelines. In an iterative process, we reviewed items for duplication and omissions and involved experts in guideline development for revisions and suggestions for items to be added. RESULTS: We developed a checklist with 18 topics and 146 items and a webpage to facilitate its use by guideline developers. The topics and included items cover all stages of the guideline enterprise, from the planning and formulation of guidelines, to their implementation and evaluation. The final checklist includes links to training materials as well as resources with suggested methodology for applying the items. INTERPRETATION: The checklist will serve as a resource for guideline developers. Consideration of items on the checklist will support the development, implementation and evaluation of guidelines. We will use crowdsourcing to revise the checklist and keep it up to date.

[Trans-Identity in Minors: Basic Ethical Principles for Individual Decision-Making in Healthcare]. / Trans-Identität bei Kindern und Jugendlichen: Medizinethische Grundsätze für individuelle Behandlungsentscheidungen.

Trans-Identity in Minors: Basic Ethical Principles for Individual Decision-Making in Healthcare The treatment of minors with gender incongruence has been the subject of controversial discussion for some time. In 2020, the German Ethics Council adopted the ad-hoc recommendation "Trans-identity in children and adolescents: Therapeutic Controversies - Ethical Orientations" with the aim of sensitising to the relevant ethically problematic aspects and of setting out orienting guidelines for medical and psychotherapeutic support and treatment. According to the Ethics Council, every person has the constitutional right to lead a life in accordance with one's own gender identity and to be respected in this identity. Healthcare professionals must assess the consequences of treatment as well as the consequences of refraining to provide treatment. All interactions with the child must be designed in such a way that the child can participate in decision-making and is ultimately enabled to give full informed consent. Stigmatisation and discriminatory pathologisation of gender incongruence must be avoided.

[Quality deficits of drug trials for older patients: An analysis of a series of systematic reviews]. / Auf welcher methodischen Qualität basieren unsere medizinischen Empfehlungen für ältere Menschen? Eine Analyse am Beispiel einer Serie von Systematischen Übersichtsarbeiten im Rahmen des PRIMA-eDS Projekts.

INTRODUCTION: The aim of this work is to present an exemplary methodological review of the quality of included studies on drug therapy in older patients, using a published series of six systematic reviews (SRs). These six SRs included 48 systematic reviews, 65 intervention studies and 33 observational studies. The series of SRs has been carried out in the PRIMA-eDS-project (www.prima-eds.eu) to develop recommendations for the treatment of elderly patients with polypharmacy. METHODS: The research question was to which extent recommendations on drug therapy in older patients are based on sound evidence. To this purpose, we performed a quality assessment of all studies included using AMSTAR for systematic reviews, CASP for observational studies, and the Cochrane "Risk of Bias" tool for intervention studies. RESULTS: The evidence base for commonly prescribed drugs in the elderly is weak. The studies identified by the systematic reviews revealed a significant lack of studies addressing the target population as well as a lack of high-quality evidence. Among the 33 observational studies, it was unclear in nearly half of the publications whether the follow-up was sufficiently long and complete. For one-third, the conclusions did not match the observed evidence. The greatest risk of bias in the intervention trials was due to selection and incorrect blinding. Quality deficits of the systematic reviews consisted in the provision of a complete study list and the lack of consideration of potential publication bias. DISCUSSION: Overall, many methodological deficits were revealed, making it difficult or almost impossible to derive reliable recommendations. CONCLUSION: Our work illustrates the immense need for research in the treatment of older patients as well as the importance of ensuring the highest quality standards when conducting intervention and observational studies or carrying out systematic reviews.

[Primary Prevention of Acute Stroke]. / Primärprävention des Hirnschlags.

Primary Prevention of Acute Stroke Abstract. Strokes are frequent. Vascular risk factors are increasing the stroke risk. Most vascular risk factors are treatable. Their therapy is important in the primary prevention of stroke. According to the INTERSTROKE study, arterial hypertension, inactivity, overweight, dyslipidemia, smoking, unhealthy diet, cardiac pathologies such as major arrhythmia, diabetes mellitus, stress/depression and overconsumption of alcohol are the most important treatable vascular risk factors. In this article, we will also report on at present less well known treatable vascular risk factors such as sleep apnea, atheromatosis of the aortic arch and of arteries supplying the brain, migraine with aura and chronic inflammatory disorders and infections.

[Clinical Practice Guidelines: An Ambiguous Term With Potentially Unexpected Legal Consequences]. / Klinische Leitlinien: ein mehrdeutiger Begriff mit potenziell unerwarteten juristischen Konsequenzen.

Clinical Practice Guidelines: An Ambiguous Term With Potentially Unexpected Legal Consequences Abstract. The term "Clinical Practice Guidelines (CPG)" is not applied consistently in Switzerland. The FMH published a definition in 1999. However, documents not corresponding to the definition are sometimes also called CPG, while those corresponding to it are sometimes titled with other terms, such as "(klinische) Richtlinien", "Empfehlungen" or "Stellungnahmen". This heterogeneity in terminology could lead to clinical uncertainty and potentially unintended (or at least unpredicted) legal consequences. Ill-defined CPG could lead to inappropriate use of these documents in criminal, civil and public law procedures. On the other hand, an agreement on a unified use of the CPG terms would help to improve their quality and legal certainty.

[GRADE: Using evidence to decision frameworks for adoption, adaptation and de novo generation of trustworthy guideline recommendations - GRADE-ADOLOPMENT]. / GRADE Evidence-to-Decision-Tabellen für die Übernahme, Anpassung und De-novo-Entwicklung von vertrauenswürdigen Empfehlungen: GRADE-ADOLOPMENT.

BACKGROUND: Guideline developers can: (1) adopt existing recommendations from others; (2) adapt existing recommendations to their own context; or (3) create recommendations de novo. Monetary and nonmonetary resources, credibility, maximization of uptake, as well as logical arguments should guide the choice of the approach and processes. OBJECTIVES: To describe a potentially efficient model for guideline production based on adoption, adaptation, and/or de novo development of recommendations utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks. STUDY DESIGN AND SETTING: We applied the model in a new national guideline program producing 22 practice guidelines. We searched for relevant evidence that informs the direction and strength of a recommendation. We then produced GRADE EtDs for guideline panels to develop recommendations. RESULTS: In two waves, a total of 80 EtD frameworks was produced approximately 4 months and 146 EtDs in about 6 months. Use of the EtD frameworks allowed panel members to understand judgments of other guideline groups about the criteria that bear on guideline recommendations and then make their own judgments about those criteria in a systematic approach. CONCLUSION: The "GRADE-ADOLOPMENT" approach to guideline production combines adoption, adaptation, and, as needed, de novo development of recommendations. If guideline developers apply EtD criteria more widely and make their work publically available, this approach should prove even more useful.

[GRADE: Evidence to Decision (EtD) frameworks - a systematic and transparent approach to making well informed healthcare choices. 2: Clinical guidelines]. / GRADE: Von der Evidenz zur Empfehlung oder Entscheidung - ein systematischer und transparenter Ansatz, um gut informierte Entscheidungen im Gesundheitswesen zu treffen. 2: Klinische Praxisleitlinien.

Clinical guidelines are based on the best available evidence and produced systematically. In this context, the transparent presentation of the decision-making process from evidence to recommendation is indispensable. The Evidence to Decision (EtD) frameworks for clinical practice recommendations enables guideline panels to structure their approach and make it comprehensible. The EtD frameworks include three main sections: formulating the question, assessing the evidence and "Additional considerations" for each criterion, and drawing conclusions. This article focuses on the selection and operationalization of those criteria of the EtD framework that are relevant for clinical recommendations in guidelines. These include the priority of the problem, benefits and harms, certainty of the evidence, importance of the outcome, balance, resource use, equity, acceptability and feasibility. To make a recommendation, a panel must consider the implication and importance of each of the above judgments. The EtD framework helps ensure consideration of key criteria that determine whether an intervention should be recommended and that judgments are informed by the best available evidence.

Development of empirical recommendations for regional hospice and palliative care networks in Germany: A qualitative study.

BACKGROUND: Internationally, efforts are underway to develop coordinated and standardized approaches for palliative care service delivery by improving service quality in hospice and palliative care networks. German legal regulations explicitly demand networking between hospice and palliative care providers. However, there is little research on models of cooperation and the building and development of hospice and palliative care networks. Research-based recommendations for network building and advancement are lacking. OBJECTIVE: The study aim was to develop empirical recommendations for the building of new and advancement of existing hospice and palliative care networks in Bavaria, Germany. METHODS: The project utilized a qualitative approach. The research project was structured in six sequential phases: 1) semi-structured individual interviews on status quo of networks, 2) a workshop including a focus group to develop definitions of key terms and prioritize major network themes, 3) semi-structured face-to-face interviews on factors enabling and inhibiting cooperation, 4) drafting of a recommendation for regional hospice and palliative care networks, 5) an online consensus survey questionnaire to rate relevance and feasibility of the draft recommendation and an internal consensus meeting to revise the draft, and 6) an expert workshop to develop examples of realization. Coordinators and chairpersons of 12 hospice and palliative care networks constitute the study population for study phases 1 to 3, 5, and 6. Network representatives partook in one (n=6), two (n=6), three (n=4), four (n=2), or all five (n=1) of the study phases 1, 2, 3, 5, and 6. Further experts participated in one (n=10) or both (n=1) of the phases 5 and 6. RESULTS: Recommendations were drafted for six thematic fields: (i) missions and aims, (ii) roles and responsibilities, (iii) coordination, (iv) communication and information channels, (v) public visibility, and (vi) funding. The whole set of recommendations was rated by 90% of the participants to be fully or somewhat important for network building and development. A total of 22 recommendations was approved. CONCLUSIONS: The call for establishing and developing standards for hospice and palliative care networks was situated within the current policy climate of Germany and the broader international community. The present recommendations can aid implementation of this request and have a strong relevance for practice.

[Physical Activity and Cancer]. / Activité physique et cancer.

Physical Activity and Cancer Abstract. This article aims to summarize the literature on the role of physical activity in cancer patients and to propose exercise programs based on studies and recommendations. Medical advances with improved early diagnosis and treatment have increased the number of cancer survivors. At the same time, the quality of life of these patients must also be improved. In the different stages of the disease physical activity has an important role to play with its beneficial effects on fatigue, physical condition, mood etc. Collaboration between health system actors and patient education are the key to success in this multi-disciplinary care.

[GRADE: Evidence to Decision (EtD) frameworks - a systematic and transparent approach to making well informed healthcare choices. 1: Introduction]. / GRADE: Von der Evidenz zur Empfehlung oder Entscheidung - ein systematischer und transparenter Ansatz, um gut informierte Entscheidungen im Gesundheitswesen zu treffen. 1: Einleitung.

In healthcare, the processes, criteria, and evidence that decision makers use to reach their judgments often remain unclear. Decision makers sometimes neglect important criteria, give undue weight to criteria, or do not use the best available evidence to inform their judgments. Thus, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) working group developed a system to support transparent decision making. The purpose of the Evidence-to-Decision (EtD) framework is to help people use evidence in a structured and transparent way to inform decisions in the context of clinical recommendations, coverage decisions, and health system, or public health recommendations and decisions. EtD frameworks include the formulation of the question, an assessment of the evidence, and drawing conclusions. EtD frameworks inform users of recommendations about judgments that were made and the evidence supporting these judgments by making the basis for decisions transparent to target audiences. EtD frameworks also facilitate dissemination of recommendations.

PERFORMANCE MEASUREMENT IN TRIBAL HOME VISITING: CHALLENGES AND OPPORTUNITIES.

Over the last several decades, performance measurement has become an increasingly prevalent requirement among human services agencies for demonstrating program progress and achieving outcomes. In the Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV), performance measurement was one of the central components of the Administration for Children and Families' cooperative agreements to tribes, urban Indian organizations, and tribal organizations. Since the inception of the Tribal MIECHV Program in 2010, the benchmark requirement was intended to be a mechanism to systematically monitor program progress and performance toward improving the quality of home-visiting programs that serve vulnerable American Indian or Alaska Native families. In this article, we examine performance measurement in the context of Tribal MIECHV, providing an overview of performance measurement, the Tribal MIECHV requirement, and how grantees experienced the requirement; we describe the existing literature on performance measurement challenges and benefits, and the specific challenges and advantages experienced by tribal grantees; and provide recommendations for performance measurement in tribal home-visiting contexts based on grantees' own experiences. This article contributes to the literature by examining performance measurement challenges and opportunities in the context of tribal communities, and provides recommendations that may inform future policy on performance measurement design and implementation in tribal communities.

[GRADE Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical practice and public health]. / GRADE-Leitlinien: 16. Von der Evidenz zur Empfehlung oder Entscheidung ­ Vorgehen nach GRADE für Tests in der klinischen Praxis und in Public Health.

OBJECTIVE: To describe the Grading of Recommendations Assessment, Development and Evaluation (GRADE) interactive Evidence to Decision (EtD) frameworks for tests and test strategies for clinical, public health or coverage decisions. STUDY DESIGN AND SETTING: As part of the GRADE Working Group's DECIDE project we conducted workshops, user testing with systematic review authors, guideline developers and other decision makers, and piloted versions of the EtD framework. RESULTS: EtD frameworks for tests share the structure, explicitness, and transparency of other EtD frameworks. They require specifying the purpose of the test, linked or related management and the key outcomes of concern for different test results and subsequent management. The EtD criteria address test accuracy and assessments of the certainty of the additional evidence necessary for decision-making. When there is no direct evidence of test effects on patient important outcomes, formal or informal modeling is needed to estimate effects. We describe the EtD criteria based on examples developed with GRADEpro (www.gradepro.org), GRADE's software that also provides interactive Summary of Findings Tables. CONCLUSION: EtD frameworks for developing recommendations and making decisions about tests lay out the sequential steps in reviewing and assessing the different types of evidence that need to be linked.

[GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations]. / GRADE Leitlinien: 14. Von der Evidenz zur Empfehlung: Die Bedeutung und Darstellung von Empfehlungen.

This article describes the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to classifying the direction and strength of recommendations. The strength of a recommendation, separated into strong and weak, is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh its undesirable effects. Alternative terms for a weak recommendation include conditional, discretionary, or qualified. The strength of a recommendation has specific implications for patients, the public, clinicians, and policy makers. Occasionally, guideline developers may choose to make "only-in-research" recommendations. Although panels may choose not to make recommendations, this choice leaves those looking for answers from guidelines without the guidance they are seeking. GRADE therefore encourages panels to, wherever possible, offer recommendations.

[GRADE guidelines 15: going from evidence to recommendation - determinants of a recommendation's direction and strength]. / Grade Leitlinien: 15. Von der Evidenz zur Empfehlung - Determinanten, die Richtung und Stärke einer Empfehlung bestimmen.

In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. This article addresses GRADE's approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention.

[Atypical fractures of the femur: apropos of 3 clinical cases]. / Fractures atypiques du fémur: A propos de trois cas cliniques.

Osteoporosis is an increasing public health problem. The bisphophonates are the most useful treatment used through the world to prevent osteoporotic fractures. Their large prescription revealed an unpredictable side effect: the atypical fracture. These fractures appear in the subtrochanteric or diaphysal femoral proximal site, spontaneously or after a low trauma, and could be bilateral. X-rays shows a transversal or oblique fracture with a spur in the cortex and with a diffuse thickening of the cortical of the proximal femur. Expert's recommendations are current in progress to well understand and managed this problem. Here we report three cases of atypical femur fractures occurred in our Centre of bone diseases with some management and treatment propositions.

L'ostéoporose est un problème croissant de santé publique. Les bisphosphonates sont les médicaments les plus utilisés dans le monde pour prévenir les fractures ostéoporotiques. Leur grande utilisation révèle une association avec un effet secondaire inattendu: les fractures atypiques du fémur. Ces dernières surviennent dans la région sous-trochantérienne ou diaphysaire proximale spontanément ou après un traumatisme mineur, et peuvent être bilatérales. La radiographie montre une fracture transversale ou oblique simple avec un «éperon¼ au niveau du cortex, et un épaississement cortical diffus du fémur proximal. Des recommandations d'experts voient le jour pour une meilleure connaissance et prise en charge. Nous rapportons trois cas de fractures atypiques survenues sous bisphosphonate avec proposition de prise en charge thérapeutique.

[Review: Patient safety as a national health goal: current state and essential fields of action for the German healthcare system]. / Übersichtsartikel: Patientensicherheit als nationales Gesundheitsziel: Status und notwendige Handlungsfelder für die Gesundheitsversorgung in Deutschland.

For some years patient safety has been an important topic for the design of the healthcare systems in many countries. In Germany we are still in the starting phase of this development. Here, patient safety is not a main focus for research and there is only little funding for these topics. Thus most findings on patient safety have been derived in foreign studies. Slowly, some find their way into the clinical routine in Germany. This paper summarises the state of development of patient safety from a trans-sectoral point of view and outlines essential fields of action for the German healthcare system.

[How to deal with preoperative hypertension]. / Präoperative Hypertonie: Wie vorgehen - einige Praxistipps.

Although there only limited supportive evidence it is suggested that in the setting of elective surgery whenever possible one should aim for a normal preoperative blood pressure in hypertensive patients. If preoperative pressure is >180 mmHg (adequate and correct blood pressure measurement technique, whenever needed 24 h-ABPM) an elective surgical intervention should be postponed and blood pressure control should be optimized. Blood pressure of <180 mmHg is regarded as no contraindication for an elective surgical intervention. The perioperative risk in suboptimally treated hypertensive patients is not elevated as long as perioperative anesthesia handling is optimal and in the absence of relevant comorbidities. In summary present evidence suggests that the pre- and perioperative hypertension is a controllable risk factor of minor relevance. However this does not mean that one should ignore elevated preoperative blood pressure values. More than ten years ago an editorialist brought it to the point by saying: "Preoperative hypertension: remain wary? Yes - cancel surgery? No".

L'hypertension est un problème régulier dans la période périopératoire. En général il est souhaitable d'avoir dans toutes les situations une pression artérielle normale. Si la pression systolique préopératoire est >180 mmHg un abaissement est souhaitable lorsqu'il s'agit d'une intervention élective des Patients avec une pression artérielle systolique <180 mmHg peuvent être opérées sans délai mais il est aussi correct d'essayer de normaliser ou du moins d'abaisser la pression bien avant l'intervention. L'évidence suggère que le risque périopératoire chez des patients avec une pression systolique <180 mmHg n'est pas augmentée s'il n'y a pas des comorbidités et avec le support d'une anesthésiologie optimale. Il y a dix ans un éditorialiste a bien résumé le problème périopératoire en disant: «Preoperative hypertension: remain wary? Yes ­ cancel surgery? No¼.