A Framework for the Development of Living Practice Guidelines in Health Care.

BACKGROUND: Living practice guidelines are increasingly being used to ensure that recommendations are responsive to rapidly emerging evidence. OBJECTIVE: To develop a framework that characterizes the processes of development of living practice guidelines in health care. DESIGN: First, 3 background reviews were conducted: a scoping review of methods papers, a review of handbooks of guideline-producing organizations, and an analytic review of selected living practice guidelines. Second, the core team drafted the first version of the framework. Finally, the core team refined the framework through an online survey and online discussions with a multidisciplinary international group of stakeholders. SETTING: International. PARTICIPANTS: Multidisciplinary group of 51 persons who have experience with guidelines. MEASUREMENTS: Not applicable. RESULTS: A major principle of the framework is that the unit of update in a living guideline is the individual recommendation. In addition to providing definitions, the framework addresses several processes. The planning process should address the organization's adoption of the living methodology as well as each specific guideline project. The production process consists of initiation, maintenance, and retirement phases. The reporting should cover the evidence surveillance time stamp, the outcome of reassessment of the body of evidence (when applicable), and the outcome of revisiting a recommendation (when applicable). The dissemination process may necessitate the use of different venues, including one for formal publication. LIMITATION: This study does not provide detailed or practical guidance for how the described concepts would be best implemented. CONCLUSION: The framework will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It will also help research methodologists study the processes of living guidelines. PRIMARY FUNDING SOURCE: None.

A Collision Tumor in the Breast Consisting of Invasive Ductal Carcinoma and Malignant Melanoma.

Collision tumors are rare neoplasms that consist of at least two different cell lineages at the same site. Given the many possible combinations that can occur, collision tumors, while rare, have been reported in multiple locations such as the stomach, bladder, and thyroid. Collision tumors are rarely found in breast tissue, with only a few cases reported in the literature. We herein report a unique case of a 79-year-old woman with a history of melanoma who presented with a left breast mass that was subsequently found to have invasive ductal carcinoma (IDC) and metastatic melanoma in the breast tissue. This is one of the first reported combinations of these two malignancies.

A Rare Case of Granular Cell Tumor in the Right Upper Lung of an Adolescent Patient.

Granular cell tumors (GCTs) are rare neoplasms of neuroectodermal origin characterized by large polygonal cells with abundant eosinophilic and granular cytoplasm. GCTs rarely affect the lungs, with only a few cases reported in the literature. The pathophysiology of this Schwann cell-derived condition is not well understood but is thought to be due to recurring genetic mutations. GCTs have been linked with Noonan syndrome. Here, we report the case of a 17-year-old caucasian male who presented with partial upper airway obstruction due to a GCT. This case promotes awareness among pathologists and clinicians for this condition in the workup of patients presenting with upper airway obstruction.

A Case Report of the Ongoing Management and Comorbidities of Loin Pain Hematuria Syndrome with an Unusual Presentation.

Loin pain hematuria syndrome (LPHS) is a rare chronic pain disorder that is poorly understood. LPHS presents as unilateral or bilateral flank pain with hematuria of unknown cause. The lack of knowledge surrounding pathogenesis and effective treatment has resulted in missed diagnoses as well as narcotic addiction in some patients. In this case, we describe the presentation and management of a 30-year-old female with a history of anxiety, depression, chronic pelvic bleeding, and pain recently diagnosed with LPHS after a total hysterectomy. She presented with ongoing pelvic pain symptoms with recent tachycardia, recurrent urinary tract infections, and nephrolithiasis. Loin pain hematuria presents as a particularly rare and difficult diagnosis to manage with multiple, sometimes unpredictable, comorbidities. This case serves as an example of a unique presentation with additional uncommon symptoms.

A Rare Case of Sarcoidosis Involving Male Breast Tissue.

Sarcoidosis is a multisystem, inflammatory granulomatous disease that rarely involves breast tissue. The pathophysiology of this chronic granulomatous condition is not well understood but is thought to be multifactorial, involving environmental influences causing an amplified immune response. A key histomorphology feature in sarcoidosis is the presence of non-necrotizing granulomas. In this case, we report a 41-year-old African-American man with a known history of sarcoidosis of the lung who presented with gynecomastia and bilateral breast tenderness with palpable nodules. Subsequent biopsy and microscopic examination of the breast nodules revealed diffuse involvement with non-necrotizing granulomas in both breasts. A final diagnosis of extensive sarcoidosis involving breast tissue was rendered after excluding other causes of non-necrotizing granulomas. The patient underwent a bilateral mastectomy to remove the breast nodules. This case discusses sarcoidosis involving an unusual site.

Improved soil biological health increases corn grain yield in N fertilized systems across the Corn Belt.

Nitrogenous fertilizers have nearly doubled global grain yields, but have also increased losses of reactive N to the environment. Current public investments to improve soil health seek to balance productivity and environmental considerations. However, data integrating soil biological health and crop N response to date is insufficient to reliably drive conservation policy and inform management. Here we used multilevel structural equation modeling and N fertilizer rate trials to show that biologically healthier soils produce greater corn yields per unit of fertilizer. We found the effect of soil biological health on corn yield was 18% the magnitude of N fertilization, Moreover, we found this effect was consistent for edaphic and climatic conditions representative of 52% of the rainfed acreage in the Corn Belt (as determined using technological extrapolation domains). While N fertilization also plays a role in building or maintaining soil biological health, soil biological health metrics offer limited a priori information on a site's responsiveness to N fertilizer applications. Thus, increases in soil biological health can increase corn yields for a given unit of N fertilizer, but cannot completely replace mineral N fertilization in these systems. Our results illustrate the potential for gains in productivity through investment in soil biological health, independent of increases in mineral N fertilizer use.

Evaluating consistency of recall of maternal and newborn care complications and intervention coverage using PMA panel data in SNNPR, Ethiopia.

BACKGROUND: There is recognition that effective interventions are available to prevent neonatal and maternal deaths but providing reliable and valid coverage estimates remains a challenge. Household surveys rely on recall of self-reported events that may span up to 5 years, raising concerns of recall bias. OBJECTIVE: This study assessed the reliability of maternal recall of pregnancy, delivery, and postpartum events over a six-month period and identified relevant individual characteristics associated with inconsistent reporting. METHODOLOGY: A longitudinal household survey was conducted with 321 pregnant women in 44 enumeration areas in Southern Nationals, Nationalities and People's Region in Ethiopia. Women who were six or more months pregnant were enrolled and interviewed at seven days, six weeks, and six months post-partum using an identical set of questions regarding maternal and neonatal health and receipt of select neonatal care interventions. We compared responses given at 7 days to those reported at 6 weeks and 6 months and conducted sensitivity, specificity, area under receiving operative curve, and Kappa analyses of selected indicators. RESULTS: We find that reporting complications is higher at the first interview after birth than at either the six-week or six-month interview. The specificity of the majority of complications is high, however sensitivity is generally much lower. The sensitivity of reporting any complication during pregnancy, delivery, or post-partum ranged from 54.5% to 67.6% at the 6-week interview and from 39.2% to 63.2% at the 6-month interview. Though sensitivity of receipt of neonatal interventions was high, specificity and kappa demonstrate low consistency. CONCLUSION: As with childbirth, it may be that during the first seven days women note symptoms with higher scrutiny, but if these do not later develop into serious health issues, they may be forgotten over time. Maternal complications and care are likely to be under-reported by women if interviewed for distant events.

Measuring health inequalities in the context of sustainable development goals.

Transforming our world: the 2030 agenda for sustainable development promotes the improvement of health equity, which entails ongoing monitoring of health inequalities. The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. Technical considerations at each step have implications for the results and conclusions of monitoring and subsequent remedial actions. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. We discuss key aspects of measuring health inequalities that are relevant to steps (i) and (iii). We highlight considerations related to the selection, measurement and categorization of dimensions of health inequality, as well as disaggregation of health data and calculation of summary measures of inequality. Inequality monitoring is linked to health and non-health aspects of the 2030 agenda for sustainable development, and strong health inequality monitoring practices can help to inform equity-oriented policy directives.

Transformer notre monde: le programme de développement durable à l'horizon 2030 promeut l'amélioration de l'équité en santé, ce qui implique un suivi continu des inégalités en matière de santé. L'Organisation mondiale de la Santé a élaboré une approche pour le suivi des inégalités en santé qui comprend plusieurs étapes: (i) déterminer la portée du suivi; (ii) collecter des données; (iii) analyser les données; (iv) communiquer les résultats; et (v) mettre en œuvre des changements. À chaque étape, des considérations techniques ont des conséquences sur les résultats et les conclusions du suivi et sur les mesures correctives qui en résultent. Ce document présente certaines considérations techniques pour le développement ou le renforcement du suivi des inégalités en santé, dans l'objectif d'encourager des pratiques plus fiables, plus systématiques et plus transparentes. Nous examinons des aspects clés de la mesure des inégalités en santé à prendre en compte dans les étapes (i) et (iii). Nous mettons en avant des considérations en lien avec la sélection, la mesure et la catégorisation des dimensions des inégalités en matière de santé, ainsi que la ventilation des données sur la santé et le calcul de mesures synthétiques des inégalités. Le suivi des inégalités est lié à des aspects sanitaires et non sanitaires du Programme de développement durable à l'horizon 2030, et des pratiques rigoureuses de suivi des inégalités en matière de santé peuvent contribuer à éclairer les directives axées sur l'équité.

Transformar nuestro mundo: el plan de 2030 para el desarrollo sostenible promueve la mejora de la igualdad en la salud, lo que implica un seguimiento continuo de las desigualdades en salud. La Organización Mundial de la Salud ha desarrollado un enfoque de múltiples pasos para el seguimiento de la desigualdad en la salud que consiste en: (i) determinar el alcance del seguimiento; (ii) obtener datos; (iii) analizar los datos; (iv) informar sobre los resultados; e (v) implementar los cambios. Las consideraciones técnicas de cada paso tienen implicaciones para los resultados y las conclusiones del seguimiento y las acciones correctivas subsiguientes. En este documento se presentan algunas consideraciones técnicas para desarrollar o fortalecer el seguimiento de la desigualdad en la salud, con el fin de fomentar prácticas más robustas, sistemáticas y transparentes. Se analizan aspectos clave de la medición de las desigualdades en la salud relevantes para los pasos (i) y (iii). Se destacan las consideraciones relacionadas con la selección, la medición y la categorización de las dimensiones de la desigualdad en la salud, así como la desagregación de los datos de salud y el cálculo de medidas sintetizadas de desigualdad. El seguimiento de la desigualdad está vinculado a los aspectos sanitarios y no sanitarios del programa de desarrollo sostenible de 2030, y unas prácticas rigurosas de seguimiento de la desigualdad en la salud pueden ayudar a fundamentar las directrices políticas orientadas a la igualdad.