Awareness, use and perception of patient versions of clinical practice guidelines - a national cross-sectional survey among patients with a cancer diagnosis and healthcare providers.

BACKGROUND: To investigate awareness, use, and perceptions of the patient guidelines (PGs) of the German Guideline Program in Oncology (GGPO) and to explore general preferences regarding cancer information among patients and healthcare providers (HCPs). METHODS: Two cross-sectional surveys among patients with cancer (November 2020-May 2021) and among HCPs (April -June 2021) were set up as anonymised, self-administered, semi-structured online surveys, including open-ended questions. Data were analysed with descriptive statistics and qualitative thematic analysis. Patients were recruited from national self-help organisations and certified cancer centres located all over Germany. HCPs were recruited from cancer centres, scientific medical societies and guideline groups. RESULTS: Of 816 participating patients, 45% were aware of the GGPO-PGs, while 55% of the 455 participating HCPs were aware of them. Of those aware of the GGPO-PGs, 65% of patients and 86% of HCPs perceived them as helpful, while 95% in both groups saw them as comprehensive. Seventy-five percent of patients and 85% of HCPs were satisfied with the GGPO-PGs, 22%/13% were partially satisfied, and 3%/2% were rather/not at all satisfied. In addition to self-help organisations, physicians and hospitals were perceived as central in distributing the GGPO-PGs. More patients (78%) than HCPs (56%) stated a preference for detailed information, although the wish for concise information - e.g. decision aids - was concurrently expressed by the majority of all participants. Thematic analysis showed that up-to-dateness, trustworthiness, and supportive messaging are important properties for PGs. CONCLUSIONS: HCPs found the GGPO-PGs helpful, but awareness was low, which suggests that dissemination should be improved. This is also true for patients; however, further research needs to be done to increase the helpfulness of PGs for patients. Oncological PGs seem to be needed in different formats according to patients' situational needs. Theory-driven research should investigate how to best frame patient information in a supportive way.

[Evidence-based medicine and clinical ethics: toward shared decision making].

Evidence-based medicine (EBM) is "decision-making for better patient care that integrates current evidence, and clinical expertise with patients' preferences, values and circumstances." It is important to distinguish research evidence from EBM, which is comprehensive decision-making that takes into account the diversity and individuality of clinical situations while respecting evidence as a general theory. Clinical practice guidelines are "a document that evaluates the total body of evidence through systematic review and presents recommendations that are considered optimal, taking into account the balance of benefits and harms, in order to support decision-making on important health-related issues by healthcare users and providers," and is useful in the practice of EBM. Shared decision making (SDM), which has been attracting attention in recent years, is "a process in which the patient and the health care provider, through dialogue, decide on a treatment plan that is acceptable to the patient, based on the patient's own preferences and values, research evidence, and clinical expertise" and must be understood in relation to the above definition of EBM and from the perspective of clinical ethics.

Quality Assessment of Periapical Radiographs Taken by Dental Assistants Using the Recent Faculty of General Dental Practice (FGDP) Guidelines.

BACKGROUND: Periapical radiographs play a pivotal role in dentistry, offering invaluable insights essential for various dental procedures. OBJECTIVE: This study aims to systematically assess the quality of intraoral periapical (IOPA) radiographs evaluating adherence to the recent guidelines established by the Faculty of General Dental Practice (FGDP). METHODS: A cross-sectional study was conducted at the University College of Dentistry (UCD), employing a non-probability consecutive sampling technique to acquire a calculated sample of 300 IOPA radiographs from the operative, oral surgery, and oral radiology departments. Two senior faculty members evaluated the radiographs according to the recent two-tier grading system outlined in the FGDP guidelines. RESULTS: The study revealed that 197 (65.67%) of the assessed radiographs were diagnostically acceptable, while 103 (34.33%) were deemed diagnostically unacceptable. Contrast problems emerged as the most prevalent issue, accounting for 85 (28.3%) of the cases. Other common problems included incorrect film positioning in 66 (22%), incorrect vertical cone angulation in 37 (12.3%), incorrect horizontal cone angulation in 11 (3.7%), and incorrect processing in 15 (5%) of the IOPA radiographs. CONCLUSION: This study revealed that approximately two-thirds of the IOPA radiographs were deemed diagnostically acceptable. However, contrast issues emerged as the predominant concern affecting image quality. These findings highlight the critical importance of continuous quality improvement initiatives in radiographic practices to enhance diagnostic precision and ensure optimal patient care.

Exploring transparent reporting and data availability in systematic reviews to identify subgroup evidence: imaging for suspected hepatocellular carcinoma in the non-cirrhotic liver.

We aim to illustrate the role of complete and transparent reporting coupled with access to data sourced from published systematic reviews, especially assisting in the identification of evidence for subgroups within the context of a rare disease. To accomplish this principle, we provide a real-world example encountered during the revision of the Dutch clinical practice guideline for hepatocellular carcinoma. Specifically, we retrieved insights from two Cochrane reviews to identify direct evidence concerning the diagnostic test accuracy of computed tomography and magnetic resonance imaging for detecting hepatocellular carcinomas in suspected patients without liver cirrhosis. Through reusing the Cochrane review authors' efforts already undertaken in their exhaustive literature search and selection, we successfully identified relevant direct evidence for this subgroup of suspected patients without cirrhosis and performed an evidence synthesis within the constraints of limited resources for the guideline revision. This approach holds the potential for replication in other subgroups in the context of rare diseases, contingent on the transparent and complete reporting of systematic reviews, as well as the availability and accessibility of their extracted data. Consequently, we underscore the importance of adhering to established reporting guidelines for systematic reviews, while simultaneously advocating for increased availability and accessibility to data. Such practices would not only increase the transparency and reproducibility of systematic reviews but could also increase reusability of their data. In turn, the increased reusability could result in reduced resource utilization in other sectors such as the guideline developing community as we show in our example.

Surgeon Alignment With Clinical Practice Guidelines: A Qualitative Analysis of Treatment of Distal Radius Fractures.

BACKGROUND: Clinical practice guidelines (CPGs) are developed to guide physicians in providing consistent high-quality care. Despite availability of evidence-based guidelines for the treatment of distal radius fractures, prior work suggests many patients receive treatment that is misaligned with the CPG. We sought to explore barriers and facilitators of guideline-aligned care for distal radius fractures. METHODS: We conducted semistructured interviews of a purposive sample of surgeons who treat distal radius fractures. Our interview guide was based on the Theoretical Domains Framework (TDF). Interviews were transcribed and coded using a deductive analytical approach within the 14 TDF domains. Belief statements underlying similar codes were developed to describe barriers and facilitators of guideline-aligned care. A content analysis was performed to count the frequency of each TDF domain. RESULTS: We interviewed 14 surgeons. The most common TDF domains were beliefs about consequences (110), knowledge (49), and social influences (29). Belief statements representative of barriers of concordance to the CPGs included, "I am more likely to deviate from the CPGs when the CPGs differ from my professional opinion," which was coded under beliefs about consequences. Similar belief statements were created for each theme within TDF domains. CONCLUSION: Decision-making for patients with distal radius fractures is driven by beliefs about consequences, knowledge, and social influences. Strategies to address these beliefs in other fields such as including patient factors in a further structured shared decision-making process, developing implementation toolkits as part of the CPG development process, and implementing payment programs may improve CPG alignment.

Implementation of WHO/PAHO Maternal Health Guidelines in the Dominican Republic / Implementación de recomendaciones de directrices de salud materna de la OMS/OPS en República Dominicana

Objective: To analyze the implementation of strong recommendations contained in the WHO and PAHO guidelines on maternal health in the Dominican Republic. Methods: A search was conducted for maternal health recommendations on the WHO's BIGG-REC platform. A total of 249 recommendations were identified: 215 strong recommendations in favor and 34 strong recommendations against, contained in 76 WHO guidelines formulated using the GRADE methodology from 2010 to 2022. These recommendations were classified into 6 domains: abortion, nutrition, hemorrhage, hypertension, infection, contraception, and public health. The characteristics and determinants that facilitate or hinder the implementation of these recommendations by the Dominican health system were analyzed. Results: 29 strong recommendations in favor were included, corresponding to the 6 domains. The recommendations with the highest level of implementation were those related to the management of obstetric hemorrhage and infection prevention. Recommendations related to abortion and public health programs had the lowest level of implementation. The main determinants for non-implementation are limitations in the legal or regulatory framework, disorganization of the service network, and social and cultural barriers. Discussion: Limitations persist in the Dominican Republic regarding the implementation of strong recommendations in maternal health from WHO guidelines. The results highlight the need to strengthen strategies for implementing recommendations in the areas of abortion care and public health interventions.

Objetivo. Analizar la implementación de las recomendaciones fuertes contenidas en las guías de la OMS y OPS sobre salud materna en la República Dominicana. Métodos: Se realizó una búsqueda de las recomendaciones de salud materna contenidas en la plataforma BIGG-REC de la Organización Mundial de la Salud (OMS). Se identificaron 249 recomendaciones: 215 recomendaciones fuertes a favor y 34 recomendaciones fuertes en contra, contenidas en 76 directrices de la OMS formuladas con metodología GRADE durante el periodo 2010-2022. Se clasificaron en 6 dominios: aborto, nutrición, hemorragia, hipertensión, infección, anticoncepción, salud pública. Se analizaron las características y los determinantes que facilitan o impiden la implementación de las recomendaciones por el sistema de salud dominicano. Resultados: Se incluyeron 29 recomendaciones fuertes a favor; correspondientes a los 6 dominios. Las recomendaciones con mayor nivel implementación fueron las relacionadas con la atención a la hemorragia obstétrica y prevención de infecciones.  Las relacionadas con Aborto y Programas de Salud Pública son las  de menor nivel de implementación. Los principales determinantes para la no implementación son limitaciones del marco legal o normativo, desorganización de la red de servicios y barreras sociales y culturales. Discusión: En República Dominicana persisten limitaciones para la implementación de recomendaciones fuertes del ámbito de la salud materna contenidas en   las directrices de la OMS. Los resultados muestran la necesidad de fortalecer estrategias para la implementación de recomendaciones en los ámbitos de atención al aborto e intervenciones de Salud Pública.

Adherence of Clinical Practice Guidelines for Oropharyngeal Dysphagia in Parkinson Disease to Trustworthy Standards: A Systematic Survey.

Despite the high prevalence and burden of dysphagia in Parkinson disease (PD), the availability and trustworthiness of clinical practice guidelines (CPGs) regarding its assessment and management remains uncertain. The objective of this study is to appraise the quality of CPGs for dysphagia in PD. We searched OVID Medline, Embase, CINAHL and SpeechBite from January 2011 to July 2023 for guidance documents addressing screening, referral, monitoring, assessment, or management of dysphagia in PD. We additionally conducted an informal search of web pages of relevant professional societies and government organizations. Paired reviewers independently screened studies, and for relevant guidance documents, abstracted data and assessed their quality using the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards instrument. Thirteen CPGs proved eligible. Of these, eight (62%) were developed by professional societies. Overall, CPGs were deemed low quality. Eleven (85%) CPGs reported funding sources, and nine (69%) reported conflicts of interest. Five (35%) guidance documents included a methodologist, four (30%) included patient partners, four (30%) described study selection processes, and two (15%) clearly described relevant benefits and harms. Regarding dysphagia-specific recommendations, less than half of guidance documents met standards for trustworthiness; six (46%) provided a synthesis of available evidence, eight (54%) specified strength of recommendations, and two (15%) articulated unambiguous recommendations. Limited guidance exists regarding screening, monitoring and referral for dysphagia in PD. Existing guidance frequently fails to meet standards for trustworthiness. International, multidisciplinary, evidence-based practice guidelines with adequate methodological and patient partner involvement are needed.

Rethinking Surgical Margins: A New Approach to Predict Outcomes in Oral Squamous Cell Carcinoma.

OBJECTIVE: The traditional categorical division of surgical margins using a 5 mm cutoff in oral cavity squamous cell carcinoma (OCSCC) is controversial. The primary aim of this study was to investigate the presence of an optimal cutoff point or, alternatively, assess the potential improvement in predictive value by considering the surgical margins as a continuum. METHODS: Retrospective analysis of OCSCC patients at a tertiary medical center in 1995-2020. Clinical, pathological, and surgical data were evaluated for effect on survivability by regression analyses. RESULTS: The cohort included 266 patients (48.1% male, mean age 65.4 ± 17.7). Patient stratification by categorical margin status yielded no significant between-group differences in survival (p = 0.54). Significance was achieved when margin distance was reevaluated as a continuous variable (p = 0.0018). Similar results were shown in local control (categorical p = 0.59 vs. continuous p = 0.06). Multivariate model excluded possible confounders. A predictive model was created to provide a more accurate prediction of survival. CONCLUSIONS: The continuum spectrum of margin distance better predicts survival outcomes and locoregional control in OCSCC. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

A swallowing and breastfeeding intervention programme for small and sick neonates embedded in kangaroo mother care.

Available evidence of oral sensorimotor interventions for small neonates is not strong. Evidence of interventions for sick term neonates is largely lacking. Studies are limited by risk of bias and inconsistency. Evidence of interventions relying on a single stimulation technique only appears to be low to very low. Ongoing research is required.Contribution: We describe a five-component neonatal swallowing and breastfeeding intervention programme embedded in the practice of kangaroo mother care (KMC). Drawing on oropharyngeal physiology, neonatology, neurodevelopmental care, breastfeeding- and KMC science, the programme is the product of collaboration between a speech-language therapist and a medical doctor, and their team. Its implementation is dependent on coaching mothers and the neonatal care team. Researchers are invited to determine outcomes of the programme.

Recommendations to improve use and dissemination of patient versions of oncological clinical practice guidelines in Germany: results of a multi-stakeholder workshop.

BACKGROUND: Oncological patients have high information needs that are often unmet. Patient versions of oncological clinical practice guidelines (PVG) translate clinical practice guidelines into laypersons' language and might help to address patients' information needs. Currently, 30 oncological PVG have been published in Germany and more are being developed. Following a large multi-phase project on oncological PVGs in Germany, recommendations to improve use and dissemination of PVG were adopted in a multi-stakeholder workshop. METHODS: Organisations representing users of PVGs (patients, medical personnel, and multipliers), creators, initiators/funding organisations of PVGs, and organisations with methodological expertise in the development of clinical practice guidelines or in patient health information were invited to participate. The workshop included a World Café for discussion of pre-selected recommendations and structured consensus procedure for of all recommendations. Recommendations with agreement of > 75% were approved, and in case of ≤ 75% agreement, recommendations were rejected. RESULTS: The workshop took place on 24th April 2023 in Cologne, Germany. Overall, 23 people from 24 organisations participated in the discussion. Of 35 suggested recommendations 28 recommendations reached consensus and were approved. The recommendations referred to the topics dissemination (N = 13), design and format (N = 7), (digital) links (N = 5), digitalisation (N = 4), up-to-dateness (N = 3), and use of the PVG in collaboration between healthcare providers and patients (N = 3). CONCLUSION: The practical recommendations consider various perspectives and can help to improve use and dissemination of oncological PVG in Germany. The inclusion of different stakeholders could facilitate the transfer of the results into practice.

Evaluation of Clinical Practice Guidelines for the Use of Supplementary Parenteral Nutrition in ICU Patients.

Background: This evaluation aims to provide a reference for clinical decision-making regarding the use of SPN in intensive care unit (ICU) patients. The objective of this study is to evaluate the quality of clinical practice guidelines for the use of supplementary parenteral nutrition (SPN) in ICU patients, both domestically and internationally. Patients and Methods: The quality of clinical practice recommendations for SPN use in ICU patients was assessed using a systematic approach. Results: Five nutrition recommendations in total were included for analysis. The average standardized scores for the recommendations across the six domains of the Appraisal of Guidelines for Research and Evaluation II (AGREE II) are as follows: Scope and purpose scored 87.96%, stakeholder Involvement scored 68.52%, rigour of development scored 73.40%, clarity of presentation scored 84.80%, applicability scored 64.72%, and editorial independence scored 91.10%. In the comprehensive evaluation, two guidelines were rated as grade A recommendations, and three were rated as grade B recommendations. Most guidelines recommended against early use of SPN when energy and protein requirements could not be met solely through enteral nutrition (EN) in ICU patients. The guidelines emphasized achieving target energy levels and discontinuing parenteral nutrition (PN) as soon as the energy requirements were met to prevent overfeeding. Conclusion: This study utilized the AGREE II scale to assess the quality of five nutrition guidelines. All 5 guidelines were deemed acceptable Recommendations include focusing on participants, rigour, and applicability to enhance guideline quality. Clinicians should exercise professional judgment when applying guidelines as they complement training and judgment, rather than replacing them.

Antimicrobial Prescription Patterns for Acute Sinusitis 2015-2022: A Comparison to Published Guidelines.

BACKGROUND: Acute rhinosinusitis (ARS) is one of the most encountered conditions in primary care and otolaryngology clinics. However, little is known about how antibiotic prescription practices following a diagnosis of ARS compare to guidelines set forth by the American Academy of Otolaryngology in 2015. OBJECTIVE: To investigate the epidemiology of ARS and the corresponding antibiotic prescribing practices by physicians and compare to published guidelines. METHODS: Using the TriNetX Live database, we identified all patients diagnosed with ARS using the ICD10 code J01 between April 2015 and December 2022 across the state of Tennessee. After investigating the demographics of this cohort, we compared the first prescribed antibiotic within one day of ARS diagnosis to published guidelines. Antibiotics were grouped into their respective classes. RESULTS: Of 81 310 patients diagnosed with ARS identified in the specified time frame, 66% were Female, 49% were African American, 44% were White, and the mean age was 47 ± 20 years. The six most common initial antibiotics prescribed for ARS were erythromycins/macrolides [14 609 (25.8%)], amoxicillin/clavulanate [14 322 (25.3%)], amoxicillin [9300 (16.4%)], third generation cephalosporins [7733 (13.6%)], quinolones [3648 (6.4%)] and tetracyclines [2235 (3.9%)]. Of this cohort, 56 719 patients (69.8%) of patients were prescribed an antibiotic within one day of diagnosis. CONCLUSION: Despite published guidelines recommending amoxicillin with or without clavulanic acid as first-line treatment for ARS, only 42.2% of prescribed antibiotics followed this guideline in our cohort. While accounting for patients with penicillin allergy, the second-most represented antibiotics were erythromycins/macrolides, which are specifically recommended against due to high rates of S. Pneumoniae resistance. Our results suggest that further investigation into the causes of erythromycin/macrolide prescriptions as first line treatment for ARS and practices at other institutions should be conducted. In addition, building awareness around published ARS guidelines for physicians may be useful in improving antibiotic stewardship in treatment of ARS.

Sex and gender bias in chronic coronary syndromes research: analysis of studies used to inform the 2019 European Society of Cardiology guidelines.

Background: Sex and gender inequalities in ischemic heart diseases persist. Although ischemic heart disease is less common in women, they experience worse clinical outcomes and are less likely to receive guideline-recommended treatments. The primary scientific literature from which clinical guideline recommendations are derived may not have considered potential sex- and gender biases. This study aims to determine whether the literature cited in recent cardiovascular guidelines' clinical recommendations contain sex and gender biases. Methods: We analysed publications cited in the 2019 European Society of Cardiology (ESC) guideline recommendations on chronic coronary syndromes, using a checklist to guide data extraction and evaluate the individual studies for sex- and gender-related aspects, such as inclusion/exclusion criteria, outcome measures, and demographic data reporting. To assess representation over time, the proportion of women participants in each study was computed and analysed using a beta regression model. We also examined the associations between women's representation, journal impact factor and author gender. Findings: Among the 20 ESC recommendations on chronic coronary syndromes, four contained sex-related statements; we did not identify any gender-specific suggestions. The referenced literature upon which these recommendations were based consisted of 108 articles published between 1991 and 2019, encompassing more than 1.6 million study participants (26.8%; 432,284 women). Only three studies incorporated sex-sensitive designs; none were gender-specific. The term "gender" did not occur in 84% (n = 91/108) of the publications; when used, it was exclusively to denote biological sex. The proportion of women (assumed by investigators) among study participants fluctuated over time. Having a woman as first (odds ratio (OR) = 1.68, 95% CI: 1.19-2.39) or last author (OR = 2.28, 95% CI: 1.31-3.97), was significantly associated with having more women participants in the study. Interpretation: The data underlying ESC guideline recommendations largely lack reporting of possible sex- and gender-specific aspects, and women are distinctly underrepresented. To what extent these recommendations apply to members of specific population groups who are not well-represented in the underlying evidence base remains unknown. Funding: This study is part of the Gender and Health Inequalities (GENDHI) project, ERC-2019-SyG. This project has received funding from the European Research Council (ERC).

Standardized treatment of oral cancer under the guidance of clinical practice guidelines of National Comprehensive Cancer Network.

Oral cancer represents a serious public health problem affecting oral and system health with a high global incidence. Treatment strategies for oral cancer vary in different disciplines and are likely to be limited to certain doctor's personal experience. While clinical practice guidelines are considered to enable doctors to determine the most appropriate and consistent treatment strategy according to the patient's situation. National Comprehensive Cancer Network (NCCN) clinical practice guidelines have become the most prevalent in global clinical oncology practice. This article mainly focuses on cases to discuss the normalized treatment strategy for oral cancer in different stages based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Head and Neck Cancers, Version 3, 2024.

Lean Six Sigma quality improvement approach to implement clinical practice guidelines for prescribing opiates for chronic pain in a primary care setting.

BACKGROUND: Implementing guidelines for chronic opioid management during a clinic merger posed significant challenges. Our aim was to increase the percentage of chronic pain evaluations and urine toxicology tests in patients on chronic opioid therapy from the baseline rate of less than 20% to 50% within 1 year at an academic, primary care clinic. METHODS: We applied the Define, Measure, Analyze, Improve, Control (DMAIC) approach of Lean Six Sigma for this quality improvement (QI) project. The QI tools included the creation of stakeholder mapping, root cause analysis, process flow mapping and a driver diagram. Lack of patient and provider education emerged as a significant barrier. The outcome measures were percentage of chronic pain evaluations and urine drug toxicology with an increase in controlled substance agreement completion rates as our process measures. Major interventions included patient and provider education, leveraging health information technology, care coordination and implementing new clinic protocols. Data analysis was performed by monthly run charts. Descriptive statistics were used to summarise clinical variables, while χ2 analyses were employed to determine statistically significant differences between preintervention and postintervention measures. RESULTS: We observed an increase in completion rates of clinic visits for chronic pain, rising from 19.0% to 51.9% (p<0.001). During study period, we observed a steady increase in chronic pain evaluations with a median of 4.5. Urine toxicology completion rates increased from 19.9% to 65.8% (p<0.001) during the preintervention and postintervention periods. We observed variable changes in urine toxicology rates with a median of 5.19. Furthermore, we observed an increase in controlled substance agreement completion rates, increasing to 50% from the baseline rate of <10%. CONCLUSIONS: Education to patients and providers, shared decision-making using a patient-centred approach, enhancement of health information technology and system-based interventions in clinic protocols and workflows contributed to the success of this QI project. The DMAIC approach may facilitate the implementation of practice guidelines for chronic opioid therapy and enhance providers' opioid prescribing practices.

National Trends in PSA Cancer Screening With Parallel Investigation of Colorectal Cancer Screening: An Analysis of the CDC Behavioral Risk Factor Surveillance System From 2012 to 2022.

INTRODUCTION/BACKGROUND: From 2012 to 2022 there have been numerous revisions in the United States Preventative Task Force guidelines for prostate cancer screening, including advising against PSA testing to allowing shared-decision making for men aged 55 to 69. We sought to observe trends in PSA testing rates in relation to the changing guidelines. Conversely, colorectal cancer screening recommendations remained consistent for patients aged 50-75 and we sought to use this as a comparison to observe the effect of differing guidelines. METHODS: The Centers for Disease Control Behavioral Risk Factor Surveillance System is a national database of surveys on health-related behaviors and preventive medical services. We extracted responses from 2012 to 2022 regarding both prostate and colorectal cancer screening. Our primary variable of interest was prostate cancer screening while colorectal cancer screening served as a positive control. RESULTS: Prostate cancer screening decreased among respondents from 70.1% in 2012 to 59.7% in 2022. However, there was a significant rebound in prostate cancer screening prevalence in 2022. In contrast, colorectal cancer screening rates steadily increased from 70.7% in 2012 to 78% in 2022. The annual percentage of men who had received prostate cancer screening was statistically different year to year. CONCLUSIONS: Trends in the rate of screening for prostate and colorectal cancer appeared to adapt to the updated recommendations. However, further investigation regarding lower income levels, minority groups, and uninsured men are essential to address the social and racial disparities seen in prostate cancer screening. Efforts to promote shared-decision making may improve effective cancer screening.

Mostly harmless? Clinical practice guidelines need further consideration of psychotherapy adverse effects.

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines on mood disorders recommend psychotherapy as foundational care for patients with acute depression with minimal discussion of any potential adverse effects. Randomised controlled trial evidence on psychotherapy adverse effects is limited. This is problematic because clinicians must balance the benefits of treatment against the harms, and clinical decisions become skewed without data on adverse effects. We suggest that clinical practice guidelines should be more guarded about recommending psychotherapy and add consensus statements on adverse effects for informed consent and clinical decision-making.

Survey of Confidence and Knowledge in Managing Patellofemoral Pain among Physical Therapists in Saudi Arabia.

BACKGROUND: This study assessed the beliefs and knowledge of physical therapists in Saudi Arabia regarding the management of patellofemoral pain (PFP) and their alignment with current Clinical Practice Guidelines (CPGs). METHODS: A cross-sectional survey was conducted, involving 111 licensed physical therapists actively treating PFP patients. The survey included questions about PFP risk factors, prognosis, diagnosis, and treatment, using a Likert scale to measure confidence and knowledge. RESULTS: Readers have significantly greater confidence in the knowledge of managing patients with PFP following current CPGs (p < 0.01). No significant differences were observed between groups in the other items (p > 0.01). However, over 70% of respondents, irrespective of guideline familiarity, held beliefs about risk factors, prognosis, diagnosis, and treatment that were inconsistent with CPGs. CONCLUSIONS: These discrepancies highlight a significant knowledge gap that may affect patient care quality. Enhancing education and dissemination efforts regarding CPGs is essential to improve adherence to evidence-based practices among physical therapists in Saudi Arabia. To change practitioners' preferences, attitudes, and beliefs, more targeted programs and interventions for knowledge dissemination and implementation should be provided.

Fragility Index Analysis of the 2018 Clinical Practice Guidelines on Tranexamic Acid Use in Total Joint Arthroplasty.

BACKGROUND: The 2018 American Association of Hip and Knee Surgeons clinical practice guideline (CPG) 'tranexamic acid use in total joint arthroplasty' evaluated the efficacy and safety of tranexamic acid in primary total joint arthroplasty. The following review assessed the statistical fragility of the randomized controlled trial (RCT) outcomes on which the CPG recommendations were based using a fragility analysis. METHODS: All dichotomous outcomes from the RCTs used to guide the CPG from its associated network, and direct meta-analyses were analyzed. Fragility and reverse fragility indices (FI and rFI) and quotients were calculated for each outcome. The mean indices and quotients were calculated for each guideline question, outcome category, and comparison of tranexamic dose, formulation, and administration timing. RESULTS: This review evaluated 403 dichotomous outcomes on transfusion and complication rates associated with tranexamic acid (TXA) administration. The mean FI of significant outcomes of the CPG was 5.23, and the mean rFI of nonsignificant outcomes was 5.80. Outcomes assessing complication rates had a mean rFI of 6.48. Most outcomes on transfusion in categories comparing TXA to placebo administration had higher mean FIs than rFIs, and all outcomes comparing transfusion risk associated with different TXA formulations and doses had higher mean rFIs than FI or no associated significant outcomes. CONCLUSIONS: The rFI and FIs calculated for this CPG are comparable to or higher than mean values reported across orthopaedic literature, indicating the relative statistical stability of its included outcomes. As we learn more about fragility analyses and their potential applications, this type of statistical analysis shows promise as a useful tool to incorporate into future guidelines to assess the quality of RCTs and evaluate the strength of recommendations.