Bridging the divide: addressing discrepancies between clinical guidelines, policy guidelines, and biomarker utilization.

OBJECTIVES: This paper aims to identify and address gaps in cancer treatment and diagnosis within European health services, focusing specifically on discrepancies between clinical guidelines and policy guidelines. It seeks to highlight how the underutilization of advanced diagnostic techniques recommended by medical societies contributes to missed opportunities for improving patient outcomes. METHODS: A comprehensive analysis was conducted across multiple European countries to assess the compliance and integration of clinical guidelines with the availability of advanced diagnostic technologies. Secondary data related to clinical and policy guidelines in cancer care were collected and analyzed. Key indicators of adoption and utilization of next-generation sequencing and liquid biopsy were examined to evaluate their impact on health service efficiency and patient care. RESULTS: The analysis revealed significant discrepancies between the recommendations of medical societies regarding advanced diagnostic techniques and their adoption in health policy decisions across Europe. Country-specific assessments indicated varying levels of alignment between clinical guidelines and the availability of advanced diagnostics. These findings underscored missed opportunities for optimizing patient care and health service efficiency through better alignment and integration of clinical guidelines with policy decisions. CONCLUSIONS: This study concludes that there is a critical need for health policy decision-makers to prioritize the adoption of clinical guidelines in resource allocation and health service organization. Greater attention to the recommendations of medical societies regarding advanced diagnostic techniques could significantly enhance diagnostic accuracy, treatment efficacy, and overall patient outcomes in cancer care. The paper advocates for policy reforms that acknowledge and leverage the potential benefits of advanced diagnostics in improving health service performance and patient-centered care across Europe.

Prevalence, awareness, treatment, and control of hypertension in community-dwelling older adults with chronic kidney disease: the Irish longitudinal study on ageing.

Background: Hypertension is highly prevalent in chronic kidney disease (CKD), posing a significant but modifiable risk for adverse clinical outcomes. This study explored the prevalence, awareness, treatment, and control of hypertension in older Irish adults with CKD. Methods: Data were analysed from participants in Wave 1 of The Irish Longitudinal Study on Ageing (TILDA) who were aged 50 years and older. CKD was defined as eGFR <60 ml/min/1.72 m2, hypertension defined as systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg and/or self-reported use of antihypertensive medication. Participant awareness and treatment of hypertension was based on self-report and SBP/DBP <140/90 mmHg. Multivariable logistic regression examined relationships with awareness, treatment, and control of hypertension expressed as adjusted odds ratios. Results: Prevalence of hypertension was significantly higher in participants with CKD than without (81.9% vs 59.7%, P < .001). Among hypertensive individuals, 70.1% (95% CI: 65.8-74.1) were aware, 83.5% (95% CI 80.0-86.6) were on treatment, yet blood pressure control <140/90 mmHg and SBP <120 mmHg were achieved in only 49.3% (CI 44.0-54.7%) and 17.9% (CI 14.4-22.1), respectively. In multivariable analysis, advancing age 1.05 (CI 1.01-1.10), obesity 6.23 (CI 2.51-15.5), diabetes 5.78 (CI 1.55-21.5), and cardiovascular disease 9.89 (CI 3.27-29.9) were associated with higher odds of treatment, while cardiovascular disease 2.35 (CI 1.39-3.99) and combination antihypertensive therapy 1.76 (CI 1.03-3.01) were associated with blood pressure control. Conclusion: The prevalence of hypertension is substantial in older Irish adults with CKD; however, control is poor. Approximately, one-third of participants were unaware of their hypertensive status and approximately one-fifth were untreated.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease.

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

[Side effects of Immune Checkpoint Inhibitors : Diagnostics and Management-an Update]. / Nebenwirkungen von Immuncheckpoint-Inhibitoren : Diagnostik und Management ­ ein Update.

Immune checkpoint inhibitors (ICI) represent a breakthrough in cancer therapy. They are effective in various tumor entities and can be used in more and more treatment settings. This leads to an increase in the number and complexity of cases with immune-related adverse events (irAE). The most common irAE are cutaneous, gastrointestinal and endocrine side effects, whereas less common irAE include pneumonitis, nephritis, myocarditis or neurological reactions. IrAE can usually be successfully treated, mainly with corticosteroids or other immunosuppressants, but they can also result in long-term sequelae or death. The optimal management of patients with steroid-refractory or steroid-dependent side effects still remains unclear. Broad awareness of these irAE across specialties is therefore of crucial importance to ensure early diagnosis and to improve irAE management.

Imaging of sudden unexpected death in infancy: a comprehensive nationwide French survey.

RATIONALE AND OBJECTIVES: Introduction of post-mortem imaging has helped improve sudden unexpected death in infancy (SUDI) management in Europe. French guidelines were issued in 2007 to homogenise SUDI investigations including imaging. The aim of this study was to evaluate current imaging management of SUDI in France. MATERIAL AND METHODS: Between January 2022 and July 2022, all 35 SUDI French referral centres were invited to answer an e-mailed online survey including 29 questions divided into four different sections covering imaging practices for SUDI including radiology department organisation, imaging modalities performed, methods of reading, and current training resources. Partial responses were secondarily completed by a personal call to the SUDI imaging consultant. The current implementation of the 2007 recommendations was compared with a previous evaluation from 2015 and with current North American practices. RESULTS: The participation rate of centres performing SUDI imaging was 100% (35/35). Imaging was systematically performed in 94.3% (33/35) of the centres: 74.3% (26/35) using radiography; 5.7% (2/35) using ultrasound; 94.3% (33/35) using computed tomography (CT), including 89% (31/35) whole-body CT and 5.7% (2/35) brain CT; and 20% (7/35) using magnetic resonance imaging (MRI). Two centres (5.7%, 2/35) did not systematically perform brain imaging. One (2.9%, 1/35) used ultrasound-guided biopsy. In comparison with 2015, rates of brain imaging increased by 25.4% (P=0.008). There was no significant difference in the number of forensic MRIs performed between France and North America (P=0.663). CONCLUSION: Despite improvements since 2015, full compliance with French guidelines for SUDI investigations remains incomplete. The use of imaging, particularly CT and brain imaging, has increased. Further efforts are needed to standardise imaging practices for optimal SUDI investigations.

Stability Indicating UPLC Method Development and Validation for the Quantitative Estimation of Pazopanib in Pure form and Marketed Pharmaceutical Dosage form.

An analytical, accurate, precise, specific, efficient and simple Ultra-Performance Liquid Chromatography method has been developed and validated for the determination of Pazopanib in bulk and was applied on marketed Pharmaceutical Dosage form. The mobile phase used for the chromatographic runs consisted of 0.1% OPA Buffer and Acetonitrile in the ratio of 30:70% v/v. The separation was achieved on a BHEL UPLC column using isocratic mode. Pazopanib Drug peak were well separated and were detected by a PDA detector at 256 nm. The developed method was linear at the concentration range 6-14 µg/ml for Pazopanib. The method has been validated according to ICH guidelines with respect to system suitability, specificity, precision, accuracy and robustness. The LOD and LOQ for the Pazopanib were found to be 0.5853 µg/ml and 1.7738µg/ml respectively. The developed method is simple, precise, specific, accurate and rapid, making it suitable for estimation of Pazopanib in bulk and marketed pharmaceutical dosage form dosage form.

Recommendations for managing adults with chronic non-cancer pain in primary care: A systematic clinical guideline review.

RATIONALE: Chronic non-cancer pain (CNCP) is a leading driver of disability. Primary care clinicians treat most patients with CNCP. Yet, they are often unable to identify appropriate pain treatments, mainly due to concerns about the safety and effectiveness of available medications. Clinical practice guidelines (CPGs) can be useful tools to guide primary care clinicians in selecting pain treatments based on the best available evidence. OBJECTIVES: To undertake a systematic review of CPGs that address the management of adults with CNCP, regardless of underlying condition type, in primary care. METHOD: We systematically reviewed and synthesised current CPGs for managing adults with CNCP in primary care (2013-2023). We followed a stepwise systematic process to synthesise key CPG recommendations: extracted and analysed each recommendation, synthesised by compiling similar recommendations using a thematic analysis approach, and assessed the strength of CPG recommendations to create a final, unified set of recommendations. We focused on identifying CPGs containing recommendations on the following topics: (a) opioid pain management, (b) non-opioid pharmacological pain management, (c) non-pharmacological pain management, and (d) patient-centred communication around pain management, prevention, and organisation of care. RESULTS: We included 13 CPGs, 8 of which focused solely on use of opioids, emphasising the lack of long-term effectiveness and safety concerns, being mainly based on the expert consensus. As an exception, high-quality evidence recommended referring patients with suspected opioid use disorder to specialist addiction services for medication-assisted treatment. Recommendations for non-opioid pain management were often contradictory and based on the expert consensus. Patient-centred pain management combined with exercise-based interventions and psychological therapies are appropriate strategies for managing patients with CNCP. CONCLUSION: Most CPGs focused on opioid management, with contradictory recommendations for non-opioid management based on low-quality evidence. Additional research is needed to strengthen the evidence for using non-opioid and non-pharmacological interventions to manage patients with CNCP.

Corrigendum: Association between meeting 24-h movement guidelines and health in children and adolescents aged 5-17 years: a systematic review and meta-analysis.

[This corrects the article DOI: 10.3389/fpubh.2024.1351972.].

A Month of Vestibular Migraine: Symptom Characterization Using Ecological Momentary Assessment.

OBJECTIVE(S): This study investigated the frequency and intensity of vestibular migraine (VM) symptoms using Ecological Momentary Assessment (EMA). This approach was intended to provide insights into the day-to-day experiences of individuals with VM, contributing to a more comprehensive understanding of this condition. METHODS: Participants reported symptoms to an automated text system, rating their dizziness over the prior 24 h as none, mild, moderate, or severe. Definitive Dizzy Days (DDDs) were defined as days with moderate or severe dizziness. A student's independent group t-test was used to compare the number of DDDs between VM and probable VM subjects. RESULTS: Sixty-six subjects were included, with an average of 29 days of pre-intervention data (SD = 1.4). The average number of days with no dizziness was 3.5 (SD = 6.5), mild dizziness was 9.1 (SD = 6.7), moderate dizziness was 11 (SD = 6.1), and severe dizziness was 5.4 (SD = 6.3). Out of the 66 patients, 52 were classified as VM and 14 as pVM. The average number of DDDs was not significantly different between VM (17.0, SD = 8.3) and pVM (15.3, SD = 10.0) patients, with a two-tailed p-value of 0.44. CONCLUSION: With EMA, we found that the average subject with VM had some degree of dizziness almost every day, and more than 15 DDDs per month. LEVEL OF EVIDENCE: III Laryngoscope, 2024.

Assessing neoadjuvant therapy recommendations in 19 national and international guidelines for rectal cancer.

BACKGROUND:  Treatment guidelines belong to the most authoritative sources of evidence-based medicine and are widely implemented by health-care providers. Rectal cancer with an annual incidence of over 730,000 new cases and nearly 340,000 deaths worldwide, remains a significant therapeutic challenge. The total mesorectal excision (TME) leads to a dramatic improvement of local control. The addition of neoadjuvant treatment has been proposed to offer further advancement. However, this addition results in significant functional impairment and a decline in the quality of life. METHODS: This review critically assesses whether the recommendation for neoadjuvant treatment in current international guidelines is substantiated. A comprehensive search was conducted in July 2022 in PubMed resulting in 988 papers published in English between 2012 and 2022. After exclusions and proofs 19 documents remained for further analysis. RESULTS: Of the 19 guidelines considered in this review, 11 do not recommend upfront surgery, and 12 do not address the issue of functional impairment following multimodal treatment. The recommendation for neoadjuvant therapy relies on outdated references, lacking differentiated strategies based on current utilisation of MRI staging; numerous guidelines recommend neoadjuvant treatment also to subgroups of patients, who may not need this therapy. Also statements regarding conflicts of interest are often not presented. CONCLUSIONS: An immediate and imperative step is warranted to align the recommendations with the latest available evidence, thereby affording rectal cancer patients a commensurate standard of care. A meticulous assessment of the guideline formulation process has the potential to avert heterogeneity in the future.

Toothbrushing programme in Saudi Arabia 'TOPS': a study protocol for a cluster randomised controlled trial in kindergartens, Riyadh.

INTRODUCTION: Dental caries among children is a major global health problem and is a particular public health challenge in Saudi Arabia. Dental caries cause pain, infection and negatively impact quality of life. As part of population oral health improvement efforts in Saudi Arabia, this project aims to evaluate the effectiveness of a supervised toothbrushing programme in kindergartens. METHODS AND ANALYSIS: This study is a cluster randomised controlled trial. Enrolment began in September 2022, for two academic years (2022-2024) on 20 randomly selected kindergartens in Riyadh. The data collection phase will be completed in September 2024. Ten kindergartens are randomly allocated to supervised toothbrushing and 10 to treatment as usual, which is an annual oral health awareness visit. The primary endpoint will be the worsening of obvious decay experience as measured by decayed (into dentine), missing and filled teeth (d3mft) from baseline to the second year of follow-up. The secondary endpoint will be the increase in the number of teeth affected. A priori subgroups of the region of Riyadh, school type (public, private), child sex and presence/absence of prior decay at baseline, will be analysed. We require 244 evaluable endpoints using a power of 80% to meet the sample size requirement. In addition, questionnaires on behaviours, quality of life, process monitoring and cost analysis are being deployed. ETHICS AND DISSEMINATION: Ethics approval for this study was given by the King Fahad Medical City Institutional Review Board in the Saudi Ministry of Health (22-083E/March 2022). The data analysis has been approved by the University of Glasgow Medical Veterinary and Life Sciences Research Ethical Committee (200220194/March 2023). The results of this study will be disseminated through presentations at scientific conferences and in scientific journals. TRIAL REGISTRATION NUMBER: NCT05512156.

Retrospective Validation of Brain Injury Guidelines in a Rural Level II Trauma Center.

INTRODUCTION: The routine transfer of mild to moderate traumatic brain injuries (TBIs) to trauma centers with neurosurgical capabilities has recently been re-evaluated. The Brain Injury Guidelines (BIG) were developed to categorize TBI patients into three categories (BIG-1, BIG-2, and BIG-3), each representing a progressively increasing risk of clinical deterioration. This classification system has been previously validated at both level I and level III trauma centers. The authors hypothesized the population of their rural level II trauma center would further validate the BIG criteria. METHODS: Using the institutional trauma registry, a retrospective analysis was performed on all patients with isolated TBIs who presented to our rural level II trauma center from 2018 to 2022. Patients were categorized according to the previously validated BIG criteria. All head computed tomography (CT) imaging studies were reviewed by one neurosurgeon. Outcomes and adverse events were compared to previously published data. RESULTS: Four hundred fifty four patients were captured with our inquiry; 138 matched BIG-1 criteria, 51 matched BIG-2 criteria, and 263 matched BIG-3 criteria. Two patients in BIG-1 (6%) and two patients in BIG-2 (12.5%) showed progression of their bleed on CT. No patients in BIG-1 or BIG-2 groups, including those showing progression on repeat CT, required a neurosurgical intervention. CONCLUSIONS: Our results support the suppositions of the BIG authors who suggest patients categorized as BIG-1 or BIG-2 do not require repeat head CT scans, neurosurgery consultation, or transfer to a tertiary center.

GRADE Guidance 39: Using GRADE-ADOLOPMENT to adopt, adapt or create contextualized recommendations from source guidelines and evidence syntheses.

INTRODUCTION: The GRADE-ADOLOPMENT methodology has been widely used to adopt, adapt or de novo develop recommendations from existing or new guideline and evidence synthesis efforts. This guidance refines the operationalization for applying GRADE-ADOLOPMENT. METHODS: Through iterative discussions, online meetings and email communications, the GRADE-ADOLOPMENT Project Group drafted the updated guidance. We then conducted a review of handbooks of guideline-producing organizations, and a scoping review of published and planned Adolopment guideline projects. The lead authors refined the existing approach based on the scoping review findings and feedback from members of the GRADE Working Group. We presented the revised approach to the group in November 2022 (approximately 115 people), in May 2023 (approximately 100 people) and twice in September 2023 (approximately 60 and 90 people) for approval. RESULTS: This GRADE guidance shows how to effectively and efficiently contextualize recommendations using the GRADE-ADOLOPMENT approach by: (1) showcasing alternative pathways for starting an adolopment effort; (2) elaborating on the different essential steps of this approach, such as building on existing EtDs when available or developing new EtDs if necessary; and (3) providing examples from adolopment case studies to facilitate the application of the approach. We demonstrate how to use contextual evidence to make judgments about EtD criteria, and highlight the importance of making the resulting EtDs available to facilitate adolopment efforts by others. CONCLUSION: This updated GRADE guidance further operationalizes the application of GRADE-ADOLOPMENT based on over six years of experience. It serves to support uptake and application by end users interested in contextualizing recommendations to a local setting or specific reality in a short period of time or with limited resources.

Endeavours made by trade associations, pharmaceutical companies and regulators in the replacement, reduction and refinement of animal experimentation in safety testing of pharmaceuticals.

Following the European Commission decision to develop a roadmap to phase out animal testing and the signing of the US Modernisation Act, there is additional pressure on regulators and the pharmaceutical industry to abandon animal experimentation in safety testing. Often, endeavours already made by governments, regulators, trade associations, and industry to replace, reduce and refine animal experimentation (3Rs) are unnoticed . Herein, we review such endeavours to promote wider application and acceptance of 3Rs. ICH guidelines have stated 3Rs objectives and have enjoyed many successes driven by global consensus. Initiatives driven by US and European regulators such as the removal of the Abnormal Toxicity Test are neutralised by reticent regional regulators. Stream-lined testing requirements have been proposed for new modalities, oncology, impurity management and animal pharmacokinetics/metabolism. Use of virtual controls, value of the second toxicity species, information sharing and expectations for life-threatening diseases, human specific or well-characterised targets are currently being scrutinised. Despite much effort, progress falls short of the ambitious intent of decisionmakers. From a clinical safety and litigation perspective pharmaceutical companies and regulators are reluctant to step away from current paradigms unless replacement approaches are validated and globally accepted. Such consensus has historically been best achieved through ICH initiatives.

Factors Associated With Leisure-Time Bicycling Among Adults in the United States: An Urban-Rural Comparison.

BACKGROUND: Bicycling is a healthy form of physical activity that can be performed by most adults as part of leisure-time (LT) activity. However, little is known about LT bicycling behaviors, especially in the rural areas of the United States. This study sought to contrast the prevalence and factors associated with LT bicycling in populations living in urban settings with those living in rural settings. METHODS: The 2019 Behavior Risk Factor Survey, which contains information regarding LT physical activity behaviors among adults (N = 396,261) in the United States, was used to determine the prevalence, demographic profile, and likelihood of meeting the physical activity guidelines of LT bicyclists. The 2013 National Center for Health Statistics Urban/Rural Classification Scheme was used to classify respondents living in rural and urban settings. RESULTS: Among US adults, 3.8% (95% CI, 3.7-3.9) reported LT bicycling activity, the sixth most common physical activity. Adults living in urban counties compared with rural counties had a greater prevalence of LT bicycling (3.9% vs 2.3%, respectively), with adults living in rural counties having a 34% lower probability of LT bicycling. Rural bicycling prevalence rates were lower across all demographics. Urban bicyclists, compared with rural bicyclists, cycled more months of the year. Overall, 85.5% of all bicyclists met the aerobic physical guidelines, with no differences between urban and rural bicyclists. CONCLUSIONS: Bicycling remains an important LT physical activity among adults in the United States. However, a rural-urban difference in the prevalence does exist for LT bicycling. The reasons for this disparity warrant further investigation.

Training approaches for the dissemination of clinical guidelines for NSSI: a quasi-experimental trial.

BACKGROUND: Non-suicidal self-injury (NSSI) is of high clinical relevance due to its high prevalence and negative long-term implications. In 2016, the German consensus-based clinical guidelines for diagnostic, assessment and treatment of NSSI in childhood and adolescence were published. However, research indicates that clinical guidelines are often poorly implemented in clinical practice. One crucial part of this process is the training of healthcare professionals to transfer knowledge and capacities to bring guideline recommendations into clinical practice. METHODS: The effect of three different dissemination strategies (printed educational material, e-learning, and blended-learning) on the NSSI guidelines´ recommendations was examined among 671 physicians and psychotherapists via an online-survey. The quasi-experimental study included three measurement points (before the training, after the training, 3-month follow-up) and mixed effects models were used to test for changes in knowledge, competences and attitudes toward NSSI and treatment. Moreover, the transfer of gained competences to practical work and user satisfaction were reviewed. RESULTS: With all three training formats, the intended changes of the outcome variables could be observed. Hereby, the printed educational material condition showed the lowest improvement in the scores for the 'negative attitudes toward NSSI and those who self-injure'. The training effect remained stable throughout the follow-up measurement. The highest application rate of acquired intervention techniques in clinical practice was reported for the blended-learning condition. For all three training strategies, user satisfaction was high and evaluation of training quality was positive, with printed educational material receiving the lowest and blended-learning the highest evaluations. CONCLUSIONS: In summary, all three training formats were perceived to be of high quality and seem to be suited to cover the needs of a heterogeneous group of physicians and psychotherapists. The choice of training method could be driven by considering which training goals are desired to be achieved and by the benefit-cost ratio allowing for tailored training approaches.

Creating Novel Standards for Datapoints on an Elective Orthopaedic Theatre List Document.

Introduction: Orthopaedic theatre lists are an important tool which must convey essential information to all staff to run an effective and safe theatre list. However, there are no set standards or guidelines on the components of an Orthopaedic theatre list. The objective of this study is to formulate guidelines for elective Orthopaedic theatre lists which improve efficiency and reduce errors. Materials and Methods: We looked at 326 elective Orthopaedic theatre lists from October to November 2018. Various factors such as: theatre and patient demographics, surgical team, type of anaesthesia, Surgery, acronyms and finally extra information such as allergies. Additionally, a survey was distributed to a variety of theatre staff to understand their requirements from a theatre list. Thereafter, we created a proforma for waiting list coordinators. Subsequently, we re-audited six more weeks of theatre lists (255) from November to December 2019. Results: The orthopaedic consultant in charge was noted for 100% of patients compared to 85% previously. There was an improvement in documenting the required anaesthesia such as noting 14.5% required spinal compared to 0.3% previously. Prosthesis/equipment was mentioned for 34% of patients compared to 23%. Fluoroscopy was noted as being required for 25% of patients compared to 11%. Conclusion: We believe standards should be in place in order for us to follow to ensure we carry out safe and efficient Orthopaedic theatre lists, and these standards should entail the parameters we have audited. The 'William Harvey theatre list standard' should be used as a gold standard for all elective Orthopaedic theatre lists.

Systematic Evaluation of Guidelines for the Diagnosis and Treatment of Hepatitis E Virus Infection.

Background and Aims: The hepatitis E virus (HEV) is a zoonotic disease, and infection with HEV in humans primarily causes acute infections and can progress to chronic manifestation in immunocompromised individuals. Over the past decade, guidelines for diagnosing and treating HEV infection have been developed. This study aimed to systematically assess the quality of current guidelines for diagnosing and treating HEV infection, and we analyzed the differences in guideline quality and primary recommendations and explored possible reasons for these differences. Methods: Guidelines published between 2013 and 2022 were searched, and studies were identified using selection criteria. The study assessed the quality of the included guidelines using the Appraisal of Guidelines for Research and Evaluation tool, extracted the primary recommendations in the guidelines, determined the highest level of evidence supporting the recommendations, and reclassified the evidence using the Oxford Centre for Evidence-Based Medicine grading system. Results: Seven guidelines were included in the final analysis. The quality of the guidelines varied widely. The discrepancies may have been caused by the lack of external experts, the failure to consider influencing factors in guideline application, and the lack of consideration of the public's opinion. Analysis of the heterogeneity in primary recommendations revealed differences in algorithms for managing chronic HEV infection, the dosage of ribavirin, and a low level of evidence supporting the primary recommendations. Conclusions: Guideline quality and primary recommendations vary considerably. Refinement by guideline developers and researchers would facilitate updating and applying guidelines for diagnosing and treating HEV infection.

Conflict among experts in health recommendations and corresponding public trust in health experts.

Importance: Public trust in health experts has been decreasing leading to decreased adherence to expert recommendations. Objective: To evaluate public perceptions of conflict and uncertainty among experts in healthcare recommendations and association with decreased trust in health entities for accurate health information. Methods: Analysis of the US nationally representative Health Information National Trends Survey (HINTS 6-2022). Adults aged 18 and older were respondents to the survey (unweighted n = 5,842, representing 241 million adults). The main outcome was trust in doctors, scientists and government health agencies for health information. Analyses examined trust in experts with public perceptions of conflict about recommendations and changing recommendations. Results: There was high trust in doctors for health information (95%) versus 84% in scientists and 70% in government health agencies. Only 18% have high trust in the health information on social media. Respondents who felt expert recommendations change often were less likely to have high trust (65%) in government agencies compared to those who felt that the recommendations did not often change (82%) (p < 0.01). In logistic regressions controlling for age, sex, race, education, income and trust in social media for health information perceptions of low conflict among expert health recommendations is associated with likelihood of high trust in government health agencies (OR 2.86; 95% CI 1.96-4.15). Conclusion: The public has low trust in government health agencies and perceptions of conflict among experts over recommendations is likely playing a role in the erosion of trust in health experts.