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Introduction: Clinical practice guidelines are essential tools for standardizing medical practices and improving healthcare quality. However, current guideline implementation is unsatisfactory. Barriers to guideline implementation include external environmental factors (e.g., medical personnel, medical institutions, local policies) and intrinsic characteristics (e.g., context, format, language etc.), with the latter being addressable by optimizing the guidelines themselves. This study aims to develop an appraisal tool to promote effective guideline implementation. Existing guideline implementability appraisal tools lack a clear theoretical basis, evidence of reliability and validity, and/or empirically-based guidance for effective implementation, all of which will be addressed in this study., Methods and Analysis: The research is divided into four phases: (1) Generating a theoretical framework for guideline implementability (i.e., scoping review and concept analysis method); (2) Conducting a factorial experiment (i.e., guideline users simulate the use of different guideline versions to examine the relationship between constructs in the framework and implementability), and removing constructs with weak relationships to form the final implementability theoretical framework; (3) Generating dimensions and items for the guideline implementability appraisal tool based on the constructs in the theoretical framework, conducting comprehensive reliability and validity testing, usability testing, and iterative optimization according to the COSMIN guidelines; (4) Integrating the validated tool with the STAR guideline rating system for guideline appraisal and feedback to promote guideline implementability. STRENGTHS AND LIMITATIONS: (1) Our research will follow a standardized and rigorous process for developing measurement scales, ensuring that the resulting evaluation scale for the implementability of CPGs is theoretically grounded, internally consistent between theory and practice, and reliable and valid. (2) The theoretical framework developed in our study will strengthen the validity and rationality of constructs in the real world. (3) In the confirmatory factor analysis, this study will determine the dimensions and items' weight through factor loadings, allowing for the quantification of the implementability of CPGs and providing users of the guidelines with objective evaluative results. In addition, the clinical practice guideline implementability evaluation tool developed in this study can assist guideline developers in enhancing implementability before, during, and after guideline formulation., Competing Interests: Declarations Ethics approval and consent to participate This protocol received ethical approval from the Institutional Review Board (IRB) of Southern Medical University (#Southern Medical Audit (2024) No. 012). The study has been registered at the China Clinical Trails Registry (ChiCTR2400086931) on July 15, 2024. All the participants signed the informed consent form. Consent for publication Not applicable. Competing interests The authors declare no competing interests.., (© 2024. The Author(s).)

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction., Competing Interests: None.

Background: Given the rapid expansion of research into digital health interventions (DHIs) for severe mental illness (SMI; eg, schizophrenia and other psychosis diagnoses), there is an emergent need for clear safety measures. Currently, measurement and reporting of adverse events (AEs) are inconsistent across studies. Therefore, an international network, iCharts, was assembled to systematically identify and refine a set of standard operating procedures (SOPs) for AE reporting in DHI studies for SMI., Design: The iCharts network comprised experts on DHIs for SMI from seven countries (United Kingdom, Belgium, Germany, Pakistan, Australia, United States, and China) and various professional backgrounds. Following a literature search, SOPs of AEs were obtained from authors of relevant studies, and from grey literature., Results: A thorough framework analysis of SOPs (n = 32) identified commonalities for best practice for certain domains, along with significant gaps in others; particularly around the classification of AEs during trials, and the provision of training/supervision for research staff in measuring and reporting AEs. Several areas which could lead to the observed inconsistencies in AE reporting and handling were also identified., Conclusions: The iCharts network developed best-practice guidelines and a practical resource for AE monitoring in DHI studies for psychosis, based on a systematic process which identified common features and evidence gaps. This work contributes to international efforts to standardize AE measurement and reporting in this emerging field, ensuring that safety aspects of DHIs for SMI are well-studied across the translational pathway, with monitoring systems set-up from the outset to support safe implementation in healthcare systems., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background and Hypothesis: The World Health Organization's (WHOs) Mental Health Gap Action Programme (mhGAP) aims to improve healthcare for mental, neurological, and substance use disorders in nonspecialized settings, with a focus on low- and middle-income countries (LMICs). mhGAP includes guidelines for the treatment of psychoses (including schizophrenia), which were recently updated in 2023. The complexity of the WHO guideline update process and the updated recommendations on psychoses are presented., Study Design: The WHO guideline development process is outlined as well as the evidence appraisal and the translation of the evidence into recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The guideline update process includes a review of the literature, a compilation of systematic reviews, and extracting data related to critical and important outcomes. The updated recommendations and the justifying evidence are discussed., Study Results: The WHO mhGAP guidelines for psychoses are adapted to LMICs, and consist of 13 recommendations in 2023, whereof 5 were updated, and 1 recommendation was newly developed. Background information on how these recommendations were obtained, and significant changes since the previous guideline update in 2015 are provided., Conclusions: Unlike other guidelines, the WHO must consider various countries, contextual factors, and the WHO Model Lists of Essential Medicines when developing its guidelines. A transformation of the WHO guideline for psychoses into a living guideline would ensure always up-to-date recommendations and facilitate shared decision-making., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Objective: This study examined adherence to clinical practice guidelines (CPGs) and U.S. Food and Drug Administration (FDA) medication labels when prescribing psychotropic medications to Medicaid-insured children with attention-deficit hyperactivity disorder (ADHD)., Methods: A retrospective analysis was conducted with 2016-2018 Medicaid claims data across 46 states for children with an ADHD diagnosis and at least one psychotropic medication prescription (N=1,236,068 children). Medications recommended for pediatric use were identified with CPGs from the American Academy of Child and Adolescent Psychiatry and the Florida Medicaid Drug Therapy Management Program for Behavioral Health., Results: Across 46 states, 86.7% of children received guideline-recommended and FDA-approved medications for the treatment of ADHD and comorbid mental disorders. Antidepressants, antihistamines, and second-generation antipsychotics that were not included in CPGs were prescribed for 23.4% of children., Conclusions: High adherence to CPGs and FDA medication labels for medications prescribed for ADHD was observed, suggesting the effectiveness of guidelines in driving evidence-based care., Competing Interests: Dr. Naylor is the psychiatric consultant to the Illinois Department of Children and Family Services (DCFS) Psychotropic Medication Consent Program and is paid via a contract between the University of Illinois Chicago and DCFS. The other authors report no financial relationships with commercial interests.

Background/aims: Despite the proven benefit of the guideline-directed medical therapy (GDMT), it remains underutilized in patients hospitalized with acute heart failure (HF). We aimed to evaluate the impact of the discharge checklist on GDMT installation and the prognosis of HF patients., Methods: This study was a single-center, observational study that included all patients admitted for HF from March 2021 to February 2023. The data were retrieved from electronic medical records and discharge checklists. A comparison was conducted between the checklist group and the non-checklist group. The primary endpoint was a composite of all-cause mortality or readmission for HF within 6 months., Results: The checklist was completed for 537 patients (checklist group) and not for 187 patients (non-checklist group). The proportion of patients to whom two or more components of GDMT were prescribed was significantly higher in the checklist group than in the non-checklist group (59.6% vs 42.2%, p < 0.001). The checklist group exhibited a significantly lower primary outcome compared to the non-checklist group (27.4% vs. 36.4%, HR 0.73, 95% CI 0.55-0.98, p = 0.036). The effect of the checklist was more prominent in HF with reduced ejection fraction (HR 0.51, 95% CI 0.34-0.77, p = 0.001) than in HF with mildly-reduced and preserved ejection fraction (HR 0.91, 95% CI 0.58-1.42, p = 0.676) (p for interaction = 0.06)., Conclusion: The implementation of the discharge checklist was associated with an improvement in GDMT prescription and an improved prognosis in patients with HF with reduced ejection fraction.

Genetic testing of patients with neurodevelopmental disabilities (NDDs) is critical for diagnosis, medical management, and access to precision therapies. Because genetic testing approaches evolve rapidly, professional society practice guidelines serve an essential role in guiding clinical care; however, several challenges exist regarding the creation and equitable implementation of these guidelines. In this scoping review, we assessed the current state of United States professional societies' guidelines pertaining to genetic testing for unexplained global developmental delay, intellectual disability, autism spectrum disorder, and cerebral palsy. We describe several identified shortcomings and argue the need for a unified, frequently updated, and easily-accessible cross-specialty society guideline. ANN NEUROL 2024;96:900-913., (© 2024 The Author(s). Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: Accurate definition and operational criteria for diagnosing Parkinson's disease (PD) are crucial for evidence-based, patient-centered care., Objective: To offer evidence-based recommendations for defining and diagnosing PD, incorporating contemporary clinical, imaging, biomarker, and genetic insights., Methods: The guideline development began with the steering committee establishing key PICO (patient, intervention, comparison, outcome) questions, which were refined by the coauthors. Systematic literature searches identified relevant studies, reviews, and meta-analyses. Recommendations were drafted, evaluated, optimized, and voted upon by the German Parkinson's Guideline Group., Results: Parkinson's disease (PD) is now understood to encompass a broader spectrum of etiologies than previously recognized. Advances in molecular pathogenesis, neuroimaging, and early clinical phenotypes suggest that PD is not a uniform disease entity and is often not idiopathic. This necessitates an updated framework for PD definition and diagnosis. The German Society for Neurology now endorses a broader concept of PD, incorporating both idiopathic and hereditary forms, as opposed to the previously narrower concept of "idiopathic Parkinson syndrome." The revised guidelines recommend using the 2015 Movement Disorders Society diagnostic criteria, emphasize the importance of long-term clinical follow-up for improved diagnostic accuracy, and highlight the significance of non-motor symptoms in clinical diagnosis. Specific recommendations are provided for the use of imaging and fluid biomarkers and genetic testing to support the clinical diagnosis., Conclusion: The updated guidelines from the German Society for Neurology enhance diagnostic accuracy for PD, promoting optimized clinical care., Competing Interests: Declarations Conflicts of interest None., (© 2024. The Author(s).)

Introduction: Women continue to be underrepresented in academic anesthesiology. This study assessed guidelines in anesthesia journals over the past 5 years, evaluating differences in woman-led versus man-led guidelines in terms of author gender, quality, and changes over time. We hypothesized that anesthesia guidelines would be predominately man-led, and that there would be differences in quality between woman-led versus man-led guidelines., Methods: All clinical practice guidelines published in the top 10 anesthesia journals were identified as per Clarivate Analytics Impact Factor between 2016 and 2020. Fifty-one guidelines were included for author, gender, and quality analysis using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Each guideline was assessed across 6 domains and 23 items and given an overall score, overall quality score, and overall rating/recommendation. Stratified and trend analyses were performed for woman-led versus man-led guidelines., Results: Fifty out of 51 guidelines were included: 1 was excluded due to unidentifiable first-author gender. In total, 255 of 1052 (24%) authors were women, and woman-led guidelines (woman-first author) represented 12 of 50 (24%) overall guidelines. Eighteen percent (9 of 50) of guidelines had all-male authors, and a majority (26 of 50, 52%) had less than one-third of female authors. The overall number and percentage of woman-led guidelines did not change over time. There was a significantly higher percentage of female authors in woman-led versus man-led guidelines, median 39% vs 20% ( P = .012), as well as a significantly higher number of female coauthors in guidelines that were woman-led median 3.5 vs 1.0, P = .049. For quality, there was no significant difference in the overall rating or objective quality of woman- versus man-led guidelines. However, there was a significant increase in the overall rating of all the guidelines over time ( P = .010), driven by the increase in overall rating among man-led guidelines, P = .002. The overall score of guidelines did not increase over time; however, they increased in man-led but not woman-led guidelines. There was no significant correlation between the percentage of female authors per guideline and either overall score or overall rating., Conclusions: There is a substantial disparity in the number of women leading and contributing to guidelines which has not improved over time. Woman-led guidelines included more women and a higher percentage of women. There was no difference in quality of guidelines by first-author gender or percentage of female authors. Further systematic and quota-driven sponsorship is needed to promote gender equity, diversity, and inclusion in anesthesia guidelines., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background Context: Clinical guidelines, developed in concordance with the literature, are often used to guide surgeons' clinical decision making. Recent advancements of large language models and artificial intelligence (AI) in the medical field come with exciting potential. OpenAI's generative AI model, known as ChatGPT, can quickly synthesize information and generate responses grounded in medical literature, which may prove to be a useful tool in clinical decision-making for spine care. The current literature has yet to investigate the ability of ChatGPT to assist clinical decision making with regard to degenerative spondylolisthesis., Purpose: The study aimed to compare ChatGPT's concordance with the recommendations set forth by The North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and assess ChatGPT's accuracy within the context of the most recent literature., Methods: ChatGPT-3.5 and 4.0 was prompted with questions from the NASS Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and graded its recommendations as "concordant" or "nonconcordant" relative to those put forth by NASS. A response was considered "concordant" when ChatGPT generated a recommendation that accurately reproduced all major points made in the NASS recommendation. Any responses with a grading of "nonconcordant" were further stratified into two subcategories: "Insufficient" or "Over-conclusive," to provide further insight into grading rationale. Responses between GPT-3.5 and 4.0 were compared using Chi-squared tests., Results: ChatGPT-3.5 answered 13 of NASS's 28 total clinical questions in concordance with NASS's guidelines (46.4%). Categorical breakdown is as follows: Definitions and Natural History (1/1, 100%), Diagnosis and Imaging (1/4, 25%), Outcome Measures for Medical Intervention and Surgical Treatment (0/1, 0%), Medical and Interventional Treatment (4/6, 66.7%), Surgical Treatment (7/14, 50%), and Value of Spine Care (0/2, 0%). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-3.5 generated a concordant response 66.7% of the time (6/9). However, ChatGPT-3.5's concordance dropped to 36.8% when asked clinical questions that NASS did not provide a clear recommendation on (7/19). A further breakdown of ChatGPT-3.5's nonconcordance with the guidelines revealed that a vast majority of its inaccurate recommendations were due to them being "over-conclusive" (12/15, 80%), rather than "insufficient" (3/15, 20%). ChatGPT-4.0 answered 19 (67.9%) of the 28 total questions in concordance with NASS guidelines (P = 0.177). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-4.0 generated a concordant response 66.7% of the time (6/9). ChatGPT-4.0's concordance held up at 68.4% when asked clinical questions that NASS did not provide a clear recommendation on (13/19, P = 0.104)., Conclusions: This study sheds light on the duality of LLM applications within clinical settings: one of accuracy and utility in some contexts versus inaccuracy and risk in others. ChatGPT was concordant for most clinical questions NASS offered recommendations for. However, for questions NASS did not offer best practices, ChatGPT generated answers that were either too general or inconsistent with the literature, and even fabricated data/citations. Thus, clinicians should exercise extreme caution when attempting to consult ChatGPT for clinical recommendations, taking care to ensure its reliability within the context of recent literature., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Consensus guidelines for postoperative nausea and vomiting (PONV) prophylaxis recommend a risk-based approach in which the number of antiemetics administered is based on a preoperative estimate of PONV risk. These guidelines have been adapted by the Multicenter Perioperative Outcomes Group (MPOG) to serve as measures of clinician and hospital compliance with guideline-recommended care. However, the impact of this approach on clinical outcomes is not known., Methods: We performed a single-center, retrospective study of adult patients undergoing general anesthesia from 2018 to 2021. Risk factors for PONV were defined using MPOG definitions: female sex, history of PONV or motion sickness, nonsmoker, inhaled anesthesia >60 minutes, high-risk procedure (cholecystectomy, laparoscopic, gynecologic), and age <50 years. Adequate prophylaxis was defined using the MPOG PONV-05 metric: at least 2 agents for patients with 1 to 2 risk factors and at least 3 agents for patients with 3+ risk factors. PONV was defined as documented PONV or receipt of rescue antiemetics. To estimate the association between adequate prophylaxis and PONV, we used Bayesian binomial models with overlap propensity score weighting., Results: We included 76,703 cases (43% receiving adequate prophylaxis) with PONV occurring in 19%. In unadjusted and unweighted comparison, adequate prophylaxis was associated with increased incidence of PONV: median odds ratio 1.21 (95% credible interval [1.16-1.25]). However, after propensity score weighting and multivariable adjustment, adequate prophylaxis was associated with reduced relative and absolute risk for PONV: weighted marginal median odds ratio 0.90 [0.84-0.98] and absolute risk reduction (ARR) 1.6% [0.6%-2.6%]. There was evidence for a differential effect of adequate prophylaxis across the guideline-defined risk spectrum, with benefit seen in patients with 1 to 5 risk factors (conditional probabilities of benefit >0.81), but not in those at high predicted risk. Patient-specific, covariate-adjusted ARR was heterogeneous, with a median patient-specific conditional probability of benefit of 0.84 (95% credible interval, 0.73-0.90)., Conclusions: Guideline-directed PONV prophylaxis is associated with a modest reduction in PONV, although this effect is small and heterogeneous on the absolute scale. We found evidence for a differential association between adequate prophylaxis and PONV across the guideline-defined risk spectrum, with diminution in patients at very high predicted preoperative risk. While patient-specific benefit was heterogenous, most patients had reasonably high predicted probabilities of absolute benefit from a guideline-directed strategy. Further assessment of these associations in a multicenter setting, with more robust investigation of risk prediction methods will allow for better understanding of the optimal approach to PONV prophylaxis., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Background: No evaluation of the quality of different carotid guidelines using validated scales has been performed to date. The present study aims to analyze 3 carotid stenosis guidelines, apprizing their quality and reporting using validated tools., Methods: A survey-based assessment of the quality of the European Society for Vascular Surgery (ESVS) 2023, European Stroke Organisation (ESO) 2021, and the Society for Vascular Surgery (SVS) 2021 carotid stenosis guidelines, was performed by 43 vascular surgeons, cardiologists, neurologist or interventional radiologists using 2 validated appraisal tools for quality and reporting guidelines, the AGREE II instrument and the RIGHT statement., Results: Using the AGREE II tool, the ESVS, SVS, and ESO guidelines had overall quality scores of 87.3%, 79.4%, and 82.9%, respectively (P = 0.001) The ESVS and ESO had better scores in the scope and purpose domain, and the SVS in the clarity of presentation domain. In the RIGHT statement, the ESVS, SVS, and ESO guidelines had overall quality scores of 84.0.7%, 74.3%, and 79.0%, respectively (P = 0.001). All 3 guidelines stood out for their methodology for search of evidence and formulating evidence-based recommendations. On the contrary, were negatively evaluated mostly in the cost and resource implications in formulating the recommendations., Conclusions: The 2023 ESVS carotid stenosis guideline was the best evaluated among the 3 guidelines, with scores over 5% higher than the other 2 guidelines. Efforts should be made by guideline writing committees to take the AGREE II and RIGHT statements into account in the development of future guidelines to produce high-quality recommendations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objective: Cognitive impairment and dementia as well as affective disorders are common and debilitating syndromes that develop in people with Parkinson's disease (PwPD). The authors summarized recommendations for the 2023 updated German guidelines on "Parkinson's disease" from the German Neurological Society (DGN), focusing on the diagnosis and treatment of these disorders., Methods: The recommendations were based on literature reviews, other relevant guidelines, and expert opinions., Results: Measurements to assess cognitive and affective states were reviewed for psychometric properties, use in routine clinical practice, and availability in German. To improve mild cognitive impairment, cognitive training and physical aerobic training are recommended. To treat Parkinson's disease (PD)-related dementia, cognitive stimulation (as a non-pharmacological intervention) and acetylcholinesterase inhibitors (AChEIs, i.e., rivastigmine) are recommended. Cognitive behavioral therapy is recommended to treat depression, anxiety, and fear of progression. Physical interventions are recommended to treat depression, fatigue, and apathy. Optimized dopaminergic treatment is the first-line pharmacological strategy recommended to manage depression, apathy, anhedonia, fatigue, and mood swings. Major depression can be additionally treated using venlafaxine or desipramine, while moderate depression can be treated pharmacologically according to its clinical phenotype (psychomotor retardation or agitation) and comorbidities (e.g., sleep disturbances, pain). Venlafaxine and nortriptyline can be used to treat anhedonia, while citalopram can be used for anxiety., Conclusions: In addition to the updated pharmacological treatment options, new insights into recommendations for standardized diagnostics and non-pharmacological interventions were provided for the German health care system. However, more studies are needed to explore the full potential of non-pharmacological interventions to treat and prevent cognitive impairment and affective disorders., Competing Interests: Declarations Conflicts of interest EK has received grants from the German Ministry of Education and Research, General Joint Committee, Germany, the German Parkinson Society, and STADAPHARM GmbH; honoraria from AbbVie GmbH Germany; memodio GmbH Germany; license fees from Prolog GmbH, Germany. EK is one of the authors of the cognitive intervention series “NEUROvitalis” but receives no corresponding honoraria. AKF has received grants from the German Parkinson Society, the German Alzheimer’s Society, the German Parkinson Foundation, STADAPHARM GmbH and the General Joint Committee Germany as well as honoraria from Springer Medizin Verlag GmbH, Heidelberg, Germany; Springer-Verlag GmbH, Berlin; ProLog Wissen GmbH, Cologne, Germany; Seminar- und Fortbildungszentrum Rheine, Germany; LOGOMANIA, Fendt & Sax GbR, Munich, Germany; LOGUAN, Ulm, Germany; dbs e.V., Moers, Germany; STADAPHARM GmbH, Bad Vilbel, Germany; NEUROPSY, St. Konrad, Austria; Multiple Sclerosis Society Vienna, Vienna, Austria; and Gossweiler Foundation, Bern, Switzerland. AKF is one of the authors of the cognitive intervention series “NEUROvitalis” but receives no corresponding honoraria. CB reports fees for lectures and/or honour boards from AbbVie, Bial, Desitin, Kyowa Kirin, Merz, STADA Pharma, TAD Pharma, UCB, Zambon. He has received royalties from Thieme Press and Kohlhammer Press and reports funding from Hilde-Ulrichs-Stiftung für Parkinsonforschung. KW has received funding from the Deutsche Forschungsgemeinschaft (German Research Association) and STADAPHARM GmbH outside the present study. He has received honoraria for presentations/advisory boards/consultations from BIAL, Indorsia, Boston Scientific and STADAPHARM GmbH outside the present study. He has received royalties from Thieme Press and Elsevier Press. He serves as an editorial board member of Wileys “Parkinson’s Disease”, “Behavioural Neurology” and PLOSone. ILS reports funding from Bayer AG and travel grants from and travel grants from Desitin and the German Neurological Society outside the submitted work. Ethics approval and consent to participate Not applicable, (© 2024. The Author(s).)

Background: Clinical practice recommendations guide healthcare decisions. This study aims to evaluate the strength and quality of evidence supporting the American Heart Association (AHA)/American Stroke Association (ASA) guidelines for aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracerebral hemorrhage (ICH)., Methods: We reviewed the current AHA/ASA guidelines for aSAH and spontaneous ICH and compared with previous guidelines. Guidelines were classified based on the Class of recommendation (COR) and Level of evidence (LOE). COR signifies recommendation strength (COR 1: Strong; COR 2a: Moderate; COR 2b: Weak; COR 3: No Benefit/Harm), while LOE denotes evidence quality (LOE A: High-Quality; LOE B-NR: Moderate-Quality, Not Randomized; LOE B-R: Moderate-Quality, Randomized; LOE C-EO: Expert Opinion; LOE C-LD: Limited Data)., Results: For aSAH, we identified 84 recommendations across 15 guideline categories. Of these, 31% were classified as COR I, 30% as COR 2a, 17% as COR 2b, and 18% as COR 3. In terms of LOE, 7% were based on LOE A, 10% on LOE B-R, 65% on LOE B-NR, 14% on LOE C-LD, and 5% on LOE C-EO. Compared to previous guidelines, there was a 46% decrease in LOE A, a 45% increase in LOE B, and an 11% decrease in LOE C. For spontaneous ICH, 124 guidelines were identified across 31 guideline categories. Of these, 28% were COR I, 32% COR 2b, and 9% COR 3. For LOE, 4% were based on LOE A, 35% on LOE B-NR, and 42% on LOE C-LD. Compared to previous guidelines, there was a 78% decrease in LOE A, an 82% increase in LOE B, and a 14% increase in LOE C. This analysis highlights that less than a third of AHA/ASA guidelines are classified as the highest class of recommendation, with less than 10% based on the highest LOE., Conclusion: Less than a third of AHA/ASA guidelines on aSAH and spontaneous ICH are classified as the highest class of recommendation with less than 10% based on highest LOE. There appears to be a decrease in proportion of guidelines based on highest LOE in most recent guidelines., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To apply the 2019 joint American Academy of Neurology (AAN) and American Headache Society (AHS) quality measures for headache management to a cohort of neurology resident physicians and then assess outcomes related to guideline adherence., Background: The optimization of headache management is essential to reduce both the individual and systemic impact of these disorders. In 2014, the AAN developed 10 quality measures for evidence-based management of patients with headache. A workgroup updated and condensed its headache quality measures in 2019, narrowing the set to six measurements, four of which would primarily focus on the management of migraine and two of which would address the management of cluster headache., Methods: This quality improvement study was conducted using a pretest-posttest study design. A pre-intervention survey based on retrospective analysis of five clinic notes for adherence to the measures was designed and distributed to all neurology residents (n = 32) at a large, academic tertiary referral center. The intervention included the creation of an electronic medical record template to aid residents in following the measures during clinical encounters, as well as the provision of direct feedback based on pre-intervention results. Finally, a post-intervention survey was distributed for completion based on notes written during the intervention period. Analysis was limited to migraine, given the low percentage of cluster headache seen in clinic., Results: An increase in adherence was seen in three of the four migraine-related quality measures, with the Use of Abortive Medications for Migraine and Documentation of Counseling on Modifiable Lifestyle and Chronification Factors demonstrating statistically significant improvements (75.8% to 88.0% [p = 0.013] and 83.9% to 94.0% [p = 0.029] adherence, respectively). For secondary outcomes, the increase in the utilization of appropriate diagnostic criteria (82.6% to 93.2%, p = 0.018) was significant, and the self-assessed confidence rating for adherence to guidelines was significant (p < 0.001)., Conclusions: This study provides evidence that the quality improvement intervention led to increased adherence to the AAN and AHS migraine-related measures. It is anticipated that increased adherence may lead to improved patient outcomes., (© 2024 American Headache Society.)

Several recent studies have investigated the validity of precautionary practices for lymphedema risk reduction after breast cancer treatment, such as avoidance of blood pressure measurements, skin puncture, blood draws, and use of prophylactic compression during air travel. Other studies have elucidated risk factors for breast cancer-related lymphedema, such as axillary lymph node dissection and skin infection (cellulitis). Combining the current evidence base with the consensus opinion of lymphatic experts assembled at the American Cancer Society/Lymphology Association of North America Summit in October 2023, updated evidence-based risk reduction recommendations are presented for those with or at risk of breast cancer-related lymphedema. Recommendation topics include prospective surveillance, patient education, individual risk factors, exercise, blood pressure, skin care and hygiene, skin puncture and blood draws, surgical procedures, prophylactic compression, air travel, and hot climate and sauna. These recommendations will help inform education and medical choices for individuals treated for breast cancer who are at risk of or diagnosed with breast cancer-related lymphedema. More high-quality evidence is required to allow the development of risk reduction recommendations for other cancer types such as gynecological, melanoma, and head and neck. It is recommended that clinicians and organizations serving people at risk of or with lymphedema align risk reduction guidelines with the evidence-based recommendations provided within this consensus document and companion manuscripts from the American Cancer Society/Lymphology Association of North America Lymphedema Summit: Forward Momentum: Future Steps in Lymphedema Management., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Guideline development on testing is known to be difficult for guideline developers. It requires consideration of various aspects, such as accuracy, purpose of testing, and consequences on management and people-important outcomes. This can be outlined in a test-management pathway. We aimed to create and user-test a step-by-step guide for guideline developers for designing a test-management pathway., Methods: Developmental design with a co-creative strategy. We created a draft step-by-step guide, that was user tested in a workshop with 19 experts, and by interviewing 7 guideline panel members., Results: Our proposed guide consists of five blocks of signalling questions: patients/population, index test(s), current practice/comparison/control, people-important outcomes, and the link between testing and outcome(s). The user testing led to refinement of the signalling questions, the use of inclusive terminology, and addition of a test-management pathway figure with detailed explanation., Conclusions: The step-by-step guide for formulating focused guideline questions regarding healthcare related testing can help in identifying relevant characteristics of the population, tests, and outcomes and to create a test management pathway. This should facilitate the formulation of evidence-based guideline recommendations about healthcare related testing., (© 2024. The Author(s).)

Background: The process of grading and stratifying evidence in the extensive literature on neurosurgical guidelines has evolved significantly, ranging from high-quality standards to suggested options. However, the methodology for guideline development has become increasingly complex, leading to challenges in their application across various neurosurgical specialties and settings. This mini review aims to explore the practical implications of published suggestions for managing neurosurgical patients., Methods: A critical and focused collection of published literature concerning guidelines in different neurosurgical topics, from Pubmed and other sources formed the basis of this non-systematic narrative review. Only guidelines produced by neurosurgeons in the era of evidence based medicine (after 1996) were included., Results: Neurosurgical guidelines often rely on a limited number of Randomized Controlled Trials (RCTs) and Class I evidence, particularly in surgical and emergency contexts where randomization of patient treatments may conflict with established clinical practices. Challenges also include the timely update of guidelines, which sometimes lags behind rapid shifts in evidence, and varying methodologies in guideline production that can result in divergent recommendations. Geographical disparities in disease burden and literature production further influence guideline applicability, suggesting a need for greater inclusion of authors from Low- and Middle-Income Countries (LMICs) to enhance realism and global relevance. Consensus conferences and expert reviews may serve as viable alternatives to address these challenges., Conclusion: While Evidence-Based Medicine remains pivotal, critical appraisal and practical application of guidelines must consider these complexities to optimize patient care and outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Successful personalized oncology today depends on clinicians taking advantage of the extensive, evidence-based information provided by the National Comprehensive Cancer Network (NCCN) Guidelines, which arguably represent the most important advance in cancer care occurring in the last many decades. Personalized oncology also demands that clinicians present guideline information to each patient in a thorough, comprehendible and unbiased manner. Finally, the patient's ability to process that information for shared decision-making about whether an intervention is consistent with their personal preferences, goals and values is perhaps the most important ingredient in truly personalized oncology care. Here, the ethics of sometimes transgressing from the NCCN guidelines with the aim of more personalized care is discussed., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The 2022 world guidelines for falls prevention and management suggest measuring sensory function including dizziness, vision, and hearing. These variables are not included in the falls risk stratification algorithm. This study sought to investigate the utility of the guidelines and potential avenues for improvement. This study applied the falls risk stratification recommendations and reviewed the individual sensory impairment risk factor variables predictive of falls and falls risk grouping in those assessed by a frailty intervention team (FIT) based in an emergency department (ED)., Methods: Patients over 65 years old who attended the ED and had a comprehensive geriatric assessment carried out by FIT over a period of four months were included in this retrospective cross-sectional study. Patient characteristics, medication, physical and sensory function status data was retrieved and analysed with respect to falls and falls risk grouping., Results: Data was gathered retrospectively from 392 patients. Excluding those with missing data, almost all attendees were in the high-risk of falls category (n = 170, 43.4%), or the low-risk category (n = 149, 38.0%). Few people were in the intermediate-risk category (n = 19, 4.8%). Hearing loss and dizziness were significantly associated with falls incidence, whereas vision and balance were not. Hearing loss, balance and dizziness were significantly associated with risk grouping, whereas vision was not., Conclusions: Most older adults included in the analysis fell into the low- or high-risk categories, with a minority in the intermediate-risk category. This suggests that the inclusion criteria for the intermediate category could be altered for greater sensitivity. While impaired balance and vision were the most common impairments, hearing status, balance and dizziness were associated with risk group. These results, through a practical application of the world guidelines for falls to an acute clinical sample, raise the possibility of refining the falls risk stratification criteria, and highlight the capacity for additional sensory intervention to mitigate falls risk., (© 2024. The Author(s).)

Purpose: Large language models (LLM) show potential for decision support in breast cancer care. Their use in clinical care is currently prohibited by lack of control over sources used for decision-making, explainability of the decision-making process and health data security issues. Recent development of Small Language Models (SLM) is discussed to address these challenges. This preclinical proof-of-concept study tailors an open-source SLM to the German breast cancer guideline (BC-SLM) to evaluate initial clinical accuracy and technical functionality in a preclinical simulation., Methods: A multidisciplinary tumor board (MTB) is used as the gold-standard to assess the initial clinical accuracy in terms of concordance of the BC-SLM with MTB and comparing it to two publicly available LLM, ChatGPT3.5 and 4. The study includes 20 fictional patient profiles and recommendations for 5 treatment modalities, resulting in 100 binary treatment recommendations (recommended or not recommended). Statistical evaluation includes concordance with MTB in % including Cohen's Kappa statistic (κ). Technical functionality is assessed qualitatively in terms of local hosting, adherence to the guideline and information retrieval., Results: The overall concordance amounts to 86% for BC-SLM (κ = 0.721, p < 0.001), 90% for ChatGPT4 (κ = 0.820, p < 0.001) and 83% for ChatGPT3.5 (κ = 0.661, p < 0.001). Specific concordance for each treatment modality ranges from 65 to 100% for BC-SLM, 85-100% for ChatGPT4, and 55-95% for ChatGPT3.5. The BC-SLM is locally functional, adheres to the standards of the German breast cancer guideline and provides referenced sections for its decision-making., Conclusion: The tailored BC-SLM shows initial clinical accuracy and technical functionality, with concordance to the MTB that is comparable to publicly-available LLMs like ChatGPT4 and 3.5. This serves as a proof-of-concept for adapting a SLM to an oncological disease and its guideline to address prevailing issues with LLM by ensuring decision transparency, explainability, source control, and data security, which represents a necessary step towards clinical validation and safe use of language models in clinical oncology., (© 2024. The Author(s).)

Background: Multiple sclerosis (MS) misdiagnosis is common, and when discovered, frequently leads to substantial disruption to patients' lives and anxiety for clinicians. Our objective was to develop expert consensus-based guidelines about how to communicate a misdiagnosis of MS to a patient, to reduce the potential for both psychological distress and litigation., Methods: A modified Delphi method using a systematic literature review on doctor and patient experiences of the MS diagnosis communication was used to populate items for a first-round questionnaire. Our Delphi panel represented three perspectives (clinicians, people with MS, and published experts in health communication), and we recruited 18 panelists in total (6 per perspective). Consensus was defined a priori as 75% of panelists giving an item the same rating. A feedback round was undertaken with six external reviewers, naïve to the guideline development process, and the panelists. Items were reviewed by the study team and synthesized to create the finalized guidelines., Results: Consensus was reached for 45 items rated as "very important" and presented in the feedback round. The study team synthesized the 45 items to 27 items. Ten items related specifically to the communication of the MS misdiagnosis and 17 items to generic guidelines highlighted as important in the MS misdiagnosis appointment. Seven recommendations form the guidelines presented here., Conclusions: Seven consensus-based recommendations offer guidance to practising neurologists in their communication with patients in a situation that has the potential to be highly distressing, for both clinician and patient., (© 2024 The Author(s). Brain and Behavior published by Wiley Periodicals LLC.)

Background: Existing data suggested a rural-urban disparity in thrombolytic utilization for ischemic stroke. Here, we examined the use of guideline-recommended stroke care and outcomes in rural hospitals to identify targets for improvement., Methods: This retrospective cohort study included patients (aged ≥18 years) treated for acute ischemic stroke at Get With The Guidelines-Stroke hospitals from 2017 to 2019. Multivariable mixed-effect logistic regression was used to compare thrombolysis rates, speed of treatment, secondary stroke prevention metrics, and outcomes after adjusting for patient- and hospital-level characteristics and stroke severity., Results: Among the 1 127 607 patients admitted to Get With The Guidelines-Stroke hospitals in 2017 to 2019, 692 839 patients met the inclusion criteria. Patients who presented within 4.5 hours were less likely to receive thrombolysis in rural stroke centers compared with urban stroke centers (31.7% versus 43.5%; adjusted odds ratio [aOR], 0.72 [95% CI, 0.68-0.76]) but exceeded rural nonstroke centers (22.1%; aOR, 1.26 [95% CI, 1.15-1.37]). Rural stroke centers were less likely than urban stroke centers to achieve door-to-needle times of ≤45 minutes (33% versus 44.7%; aOR, 0.86 [95% CI, 0.76-0.96]) but more likely than rural nonstroke centers (aOR, 1.24 [95% CI, 1.04-1.49]). For secondary stroke prevention metrics, rural stroke centers were comparable to urban stroke centers but exceeded rural nonstroke centers (aOR of 1.66, 1.94, 2.44, 1.5, and 1.72, for antithrombotics within 48 hours of admission, antithrombotics at discharge, anticoagulation for atrial fibrillation/flutter, statin treatment, and smoking cessation, respectively). In-hospital mortality was similar between rural and urban stroke centers (aOR, 1.11 [95% CI, 0.99-1.24]) or nonstroke centers (aOR, 1.00 [95% CI, 0.84-1.18])., Conclusions: Rural hospitals had lower thrombolysis utilization and slower treatment times than urban hospitals. Rural stroke centers provided comparable secondary stroke prevention treatment to urban stroke centers and exceeded rural nonstroke centers. These results reveal important opportunities and specific targets for rural health equity interventions., Competing Interests: Dr Uchino served on data safety monitoring board for clinical trials sponsored by Genentech Inc and Evaheart Inc and as consultant for Abbott Laboratories Inc. Dr Dalton received research support from the National Institute on Aging. Dr Fonarow received research support from the Patient Centered Outcome Research Institute and National Institutes of Health and served as consultant for Abbott Pharmaceuticals, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly and Company, Jassen Pharmaceuticals, Medtronic, Merck, Novartis, and Pfizer. The other authors report no conflicts.

Accurate determination of death is a necessary responsibility of the medical profession. Brain death, or death by neurological criteria (DNC), can be legally declared after the determination of permanent loss of clinical brain function, including the capacity for consciousness, brainstem reflexes, and the ability to breathe spontaneously. Despite longstanding debates over the exact definition of brain death or DNC and how it is determined, most middle- and high-income countries have compatible medical protocols and legal policies for brain death or DNC. This review summarizes the 2023 updated guidelines for brain death or DNC determination, which integrate adult and pediatric diagnostic criteria. We discuss the clinical challenges related to brain death or DNC determination in infants and young children. We emphasize that physicians must follow the standardized and meticulous evaluation processes outlined in these guidelines to reduce diagnostic error and ensure no false positive determinations. An essential component of the brain death or DNC evaluation is appropriate and transparent communication with families. Ongoing efforts to promote consistency and legal uniformity in the declaration of death are needed. WHAT THIS PAPER ADDS: Sociocultural sensitivity and appropriate communication with families during the brain death or death by neurological criteria (DNC) evaluation are needed. A key component of the brain death or DNC evaluation is appropriate and transparent communication with families. Uniform international standards and consistent legal definitions for brain death or DNC declaration remain a necessary objective., (© 2024 Mac Keith Press.)

Competing Interests: We declare no competing interests.

Ketogenic diet therapy (KDT) is a safe and effective treatment for epilepsy and glucose transporter type 1 (GLUT1) deficiency syndrome in infancy. Complete weaning from breastfeeding is not required to implement KDT; however, breastfeeding remains uncommon. Barriers include feasibility concerns and lack of referrals to expert centres. Therefore, practical strategies are needed to help mothers and professionals overcome these barriers and facilitate the inclusion of breastfeeding and human milk during KDT. A multidisciplinary expert panel met online to address clinical concerns, systematically reviewed the literature, and conducted two international surveys to develop an expert consensus of practical recommendations for including human milk and breastfeeding in KDT. The need to educate about the nutritional benefits of human milk and to increase breastfeeding rates is emphasized. Prospective real-world registries could help to collect data on the implementation of breastfeeding and the use of human milk in KDT, while systematically including non-seizure-related outcomes, such as quality of life, and social and emotional well-being, which could improve outcomes for infants and mothers. WHAT THIS PAPER ADDS: Human milk and breastfeeding can be incorporated safely into ketogenic diet therapy. With expert guidance, human milk and breastfeeding do not reduce diet effectiveness. We show two strategies for clinical practice to include human milk. Mothers can be encouraged to continue breastfeeding., (© 2024 The Authors. Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.)

Background: Professional society guidelines are evidence-based recommendations intended to promote standardized care and improve health outcomes. Amid increased recognition of the role racism plays in shaping inequitable healthcare delivery, many researchers and practitioners have critiqued existing guidelines, particularly those that include race-based recommendations. Critiques highlight how racism influences the evidence that guidelines are based on and its interpretation. However, few have used a systematic methodology to examine race-based recommendations. This review examines hypertension guidelines, a condition affecting nearly half of all adults in the United States (US), to understand how guidelines reference and develop recommendations related to race., Methods: A systematic scoping review of all professional guidelines on the management of essential hypertension published between 1977 and 2022 to examine the use and meaning of race categories., Results: Of the 37 guidelines that met the inclusion criteria, we identified a total of 990 mentions of race categories. Black and African/African American were the predominant race categories referred to in guidelines (n = 409). Guideline authors used race in five key domains: describing the prevalence or etiology of hypertension; characterizing prior hypertension studies; describing hypertension interventions; social risk and social determinants of health; the complexity of race. Guideline authors largely used race categories as biological rather than social constructions. None of the guidelines discussed racism and the role it plays in perpetuating hypertension inequities., Discussion: Hypertension guidelines largely refer to race as a distinct and natural category rather than confront the longstanding history of racism within and beyond the medical system. Normalizing race as a biological rather than social construct fails to address racism as a key determinant driving inequities in cardiovascular health. These changes are necessary to produce meaningful structural solutions that advance equity in hypertension education, research, and care delivery., (© 2024. The Author(s).)

Background: Internationally accepted standards for trustworthy guidelines include the necessity to ground recommendations in values and preferences. Considering values and preferences respects the rights of citizens to participate in health decision-making and ensures that guidelines align with the needs and priorities of the communities they are intended to serve. Early anecdotal reports suggest that COVID-19 public health guidelines did not consider values and preferences. To capture and characterize whether and how COVID-19 public health guidelines considered values and preferences., Methods: We performed a systematic review of COVID-19 public health guidelines. We searched the eCOVID-19 RecMap platform-a comprehensive international catalog of COVID-19 guidelines-up to July 2023 and the Guidelines International Network Library-an international library of guidelines published or endorsed by Guidelines International Network member organizations-up to May 2024. We included guidelines that made recommendations addressing vaccination, masking, isolation, lockdowns, travel restrictions, contact tracing, infection surveillance, and school closures. Reviewers worked independently and in duplicate to review guidelines for consideration of values and preferences., Results: Our search yielded 130 eligible guidelines, of which 41 (31.5%) were published by national organizations, 70 (53.8%) by international organizations, and 19 (14.6%) by professional societies and associations. Twenty-eight (21.5%) guidelines considered values and preferences. Among guidelines that considered values and preferences, most did so to assess the acceptability of recommendations (23; 82.1%) and by referencing published research (25; 89.3%). Guidelines only occasionally engaged laypersons as part of the guideline development group (8; 28.6%). None of the guidelines performed systematic reviews of the literature addressing values and preferences., Conclusion: Most COVID-19 public health guidelines did not consider values and preferences. When they were considered, it was often suboptimal. Disregard for values and preferences might have partly contributed to divisive and unpopular COVID-19 policies. Given the possibility of future health emergencies, we recommend guideline developers identify efficient and effective methods for considering values and preferences in crisis situations., Competing Interests: Declaration of competing interest There are no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Supportive care clinical practice guidelines (CPGs) facilitate the incorporation of the best available evidence into pediatric cancer care. We aimed to assess the impact of the work of the Children's Oncology Group (COG) Supportive Care Guideline Task Force on institutional supportive care practices., Procedure: An online survey was distributed to representatives at 209 COG sites to assess the awareness, use, and helpfulness of COG-endorsed supportive care CPGs. Availability of institutional policies regarding 13 topics addressed by current COG-endorsed CPGs was also assessed. Respondents described their institutional processes for developing supportive care policies., Results: Representatives from 92 COG sites responded to the survey, and 78% (72/92) were "very aware" of the COG-endorsed supportive care CPGs. On average, sites had policies that addressed seven COG-endorsed supportive care CPG topics (median = 7, range: 0-12). Only 45% (41/92) of sites reported having institutional processes for developing supportive care policies. Of these, most (76%, 31/41) reported that the COG-endorsed CPGs have a medium or large impact on policy development. Compared with sites without processes for supportive care policy development, sites with established processes had policies on a greater number of topics aligned with current COG-endorsed CPG topics (mean = 6.6, range: 0-12 vs mean = 7.9, range: 2-12; p = 0.027)., Conclusions: Most site respondents were aware of the COG-endorsed supportive care CPGs. Less than half of the COG sites represented in the survey have processes in place to implement supportive care policies. Improvement in local implementation is required to ensure that patients at COG sites receive evidence-based supportive care., (© 2024 Wiley Periodicals LLC.)

Background: The Choosing Wisely ® (CW) campaign recommended de-implementation of surgical management of axillary nodes in specified patients. This study aimed to assess trends in the application of CW guidelines for lymph node (LN) surgery in males with breast cancer., Methods: The National Cancer Database was queried for males diagnosed with breast cancer from 2017 to 2020. Patients were categorized into two cohorts based on CW criteria. Cohort 1 included all T1-2, clinically node-negative patients who underwent breast-conserving therapy and with ≤ 2 positive nodes, and Cohort 2 included all T1-2, node-negative, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative patients aged ≥ 70 years. In Cohort 1, patients who underwent sentinel LN biopsy (SLNB) alone were compared with axillary LN dissection (ALND) or no LN surgery, while in Cohort 2, patients who underwent LN surgery were compared with those with no LN surgery., Results: Of 617 patients who met the criteria for Cohort 1, 73.1% underwent SLNB alone compared with ALND (11.8%) or no LN surgery (15.1%). Those who received SLNB alone were younger (65 vs. 68 vs. 73 years; p < 0.001). The annual proportion of males who underwent SLNB alone remained stable from 2017 to 2020. Overall, 1565 patients met the criteria for Cohort 2, and 84.9% received LN surgery. LN surgery was omitted in older patients (81 vs. 77; p < 0.001). The proportion of elderly males with early-stage breast cancer who underwent LN surgery increased from 2017 to 2020., Conclusion: This study demonstrates that CW recommendations are not being routinely applied to males. These findings reinforce the need for additional studies and subsequent recommendations for optimal application of axillary surgery de-implementation for males diagnosed with breast cancer., (© 2024. The Author(s).)

Primary hyperparathyroidism (PHPT) is a common endocrine disease characterized by hypercalcemia due to inappropriately high parathyroid hormone secretion. While in the typical, symptomatic form of the disease diagnosis is set easily and standard management is surgical removal of the hyperfunctioning parathyroid (HP), this may not be the case in more subtle forms of PHPT, such as the asymptomatic and the normocalcemic PHPT. Localization of the HP could also be challenging, especially in small-sized adenomas, ectopic lesions or multiglandular disease. An experienced surgical team is essential to achieve curative parathyroidectomy. In this article, we used illustrative clinical vignettes to dissect the approach to the patient with PHPT, from the diagnosis establishment to the suggested investigation to identify classical and non-classical PHPT features and the methodology to locate the abnormal tissue. Accordingly, we elaborated on appropriate management, both surgical and conservative., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objective: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-ADOLOPMENT methodology has been widely used to adopt, adapt, or de novo develop recommendations from existing or new guideline and evidence synthesis efforts. The objective of this guidance is to refine 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 doing the following: (1) showcasing alternative pathways for starting an adolopment effort; (2) elaborating on the different essential steps of this approach, such as building on existing evidence-to-decision (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 6 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., Competing Interests: Declaration of competing interest The authors are members or contributors to the GRADE working group. Zachary Munn is supported by an NHMRC investigator grant APP 1195676. Alexander G. Mathioudakis was supported by the National Institute for Health and Care Research Manchester Biomedical Research Centre (NIHR Manchester BRC, NIHR203308) and by an NIHR Clinical Lectureship in Respiratory Medicine. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care., (Copyright © 2024. Published by Elsevier Inc.)

Background: In response to the COVID-19 pandemic, the Pandemic Breast Cancer Consortium (PBCC) published recommendations for triage of breast cancer patients. The recommendations included neoadjuvant treatment of early-stage breast cancer patients experiencing delays in surgery. This study evaluated national patterns of neoadjuvant treatment according to triage guidelines., Methods: Patients treated with surgery (upfront or post-neoadjuvant) in 2018-2020 were collected from the National Cancer Database. The proportions of patients treated according to the PBCC triage guidelines were calculated in 2020 and compared with similar cohorts in 2018-2019. Patient and hospital factors were evaluated for association with treatment., Results: Among cT1N0 ER+/PR+/HER2- patients, those treated in 2020 were more likely to receive neoadjuvant endocrine therapy (NET) compared with those before that time (odds ratio [OR], 3.08; range, 2.93-3.24). Among the patients with cT2N0 or cT1N1 disease, NET was more common in 2020 (OR, 1.76; range, 1.65-1.88). Academic facility, black or Asian race, more comorbidities, and the New England/Middle Atlantic region were associated with NET use., Conclusions: During the COVID-19 pandemic, expanded utilization of neoadjuvant therapy for surgical breast cancer patients was observed. Health care system limitations during the pandemic contributed to expanded adoption of neoadjuvant therapy for early breast cancer, contrary to usual practice. Long-term outcomes for patients treated according to PBCC recommendations should be closely monitored., (© 2024. The Author(s).)

Purpose of Review: There is no diagnostic biomarker that can reliably detect Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP). Diagnosis relies upon integrating key clinical characteristics and relevant supportive data. Consequently, misdiagnosis and delayed diagnosis are common. Diagnostic criteria have proven valuable resources to improve diagnosis, but are underutilized during routine clinical care., Recent Findings: In 2021, the EAN/PNS CIDP criteria was published, and were followed by the EAN/PNS GBS criteria in 2023. Both guidelines utilized GRADE methodology to formulate evidence-based recommendations that are intended to be used by adult and paediatric clinicians across diverse care settings to optimize diagnostic accuracy and improve patient outcomes during routine clinical care., Summary: The EAN/PNS GBS and CIDP criteria detail specific clinical, electrophysiological, and laboratory features that raise diagnostic confidence, and call attention to diagnostic mimics. The sensitivity of EAN/PNS and other modern criteria to detect GBS and CIDP is high, but utilization during clinical practice is low. Complexity is one factor limiting widespread application. Strategies are needed to optimize criteria adoption during routine clinical care such that GBS and CIDP diagnosis can be achieved with greater speed and accuracy., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines., Methods: We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE)., Results: Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation., Conclusions: Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In response to growing evidence that proper performance of operative techniques during cancer surgery is associated with improved patient outcomes, the American College of Surgeons (ACS) implemented six operative standards as part of Commission on Cancer (CoC) accreditation. This study aimed to assess surgeon familiarity with these standards when first introduced and 2 years after their adoption., Methods: The ACS Cancer Surgery Standards Program distributed an anonymous 36-question survey to CoC-accredited cancer programs in 2021 and 2023. Questions specific to operative techniques determined the Surgery Score, and those specific to the accreditation standards determined the Standards Score. Mean scores were compared using one-way analysis of variance (ANOVA) and t tests., Results: The survey was completed by 376 surgeons in 2021 and 380 surgeons in 2023. The Surgery Scores were higher than the Standards Scores in 2021 and 2023. The surgeons who practiced at institutions with CoC accreditation had significantly higher Standards Scores than the surgeons at non-accredited institutions in 2021 (p = 0.005) and 2023 (p = 0.004), but not significantly different Surgery Scores., Conclusions: The baseline survey in 2021 demonstrated significant knowledge of technical aspects of cancer surgery among a broad surgeon base, but a need for greater understanding of the accreditation standards. The repeat survey distribution 2 years after rollout of the operative standards and associated educational programing showed increased awareness surrounding the operative standards in 2023 and a trend toward improvement in knowledge of the accreditation standards across all specialties. Further evaluation will be directed toward compliance with the accreditation standards., (© 2024. Society of Surgical Oncology.)

Background: Several concerns have been raised over the past several years about the potential for overuse of vascular interventions for peripheral artery disease. These interventions can have serious complications, including limb loss. Given that the natural history of intermittent claudication rarely includes limb loss, it is critically important that interventions to treat it have appropriate indications., Methods: To address this matter, the Society for Vascular Surgery published an appropriate use criteria (AUC) document for the management of intermittent claudication in 2022. Using the rigorously studied University of California Los Angeles RAND Appropriateness Method, the rating panel assessed the appropriateness of 2,280 scenarios for [1] the initial management and [2] the management after a failed trial of exercise therapy., Results: The findings of the rating panel included that medical management and exercise therapy are appropriate initial management in all scenarios. There were several scenarios in which revascularization was also considered appropriate, mainly influenced by severity of physical limitations and favorable lesion characteristics. When considering management after a failed trial of exercise, guiding principles cited by the rating panel included durability of intervention, smoking cessation, and evidence of prior good-faith effort at exercise therapy. There were many scenarios which were indeterminate. With respect to the infrapopliteal segment, the rating panelists unanimously agreed to forgo individual scenario ratings, since they deemed the risks outweigh the benefits in all cases., Conclusions: The Society for Vascular Surgery (SVS) AUC for intermittent claudication represents an important effort to identify and reduce overuse. There are several considerations for how they should be used. The simplest application is by practicing clinicians, at the bedside, as they engage in shared decision-making with patients. The matter of their use by payors is more complex. Ideally, decisions on how to best use AUC require additional study of their performance before they are used by payors for anything. Finally, these AUC have identified a myriad of areas where evidence is lacking. The AUC provide important targets for future research to improve the care of patients with intermittent claudication., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The akinetic crisis is a well-known, rare, potentially life-threatening condition in Parkinson's disease with subacute worsening of akinesia, rigidity, fever, impaired consciousness, accompanying vegetative symptoms and transient dopa-resistance. The akinetic crisis was historically supposed to be a "withdrawal syndrome" in the sense of discontinuation of dopaminergic medication. Recently, other "withdrawal syndromes" as the specific "dopamine agonist withdrawal syndrome" or "deep brain stimulation withdrawal syndrome" have been described as emergency situations with specific subacute symptom constellations. All three conditions require immediate start of the adequate therapy to improve the prognosis. Here, the diagnostic criteria and treatment options of these three acute, severely disabling syndromes will be reported along the current guidelines of the German Parkinson Guideline Group., (© 2024. The Author(s).)

The construct of Clinical-High Risk for Psychosis (CHR-P) identifies young help-seeking subjects in putative prodromal stages of psychosis and is a central component of the Early Intervention (EI) paradigm in Mental Health, aimed at facilitating rapid entry into appropriate care pathways to prevent the onset of psychosis or mitigate is biopsychosocial consequences. This approach, which promotes an innovative culture of care for early, at risk situations, is inspired by a clinical staging concept as a guide to optimal treatment. The objective of this article is to map the existing guidelines in the field of CHR-P treatment recommendations, examine overlaps and differences, and critically evaluate blind spots to be addressed in future guideline updated. The search identified 9 guidelines focused on CHR-P or schizophrenia and other psychotic conditions but containing a specific section on CHR-P or prodromal psychosis. All guidelines acknowledge that psychosis is preceded by more or less pronounced prodromal stages, and most detail CHR-P criteria. Among guidelines, 8 out of 9 indicate cognitive-behavioural therapy as the best psychotherapeutic option and 7 out of 9 suggest that antipsychotics can be prescribed as second option in case psychosocial and/or other pharmacological interventions prove insufficient or inadequate in reducing clinical severity and subjective suffering. Antidepressants, mood stabilizers, and benzodiazepines were considered for the treatment of comorbid disorders. Only the European Psychiatric Association Guidance paper distinguished treatment recommendations for adults and minors. Agreements in treatment guidelines were discussed in light of recent meta-analytical evidences on pharmacological and non-pharmacological treatments for CHR-P, suggesting the need to provide an updated, age-sensitive consensus on how to manage CHR-P individuals., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Appropriate Use Criteria (AUC) are evidence-based criteria developed in a methodologically robust manner with the input of expert providers across a wide range of disciplines and practice settings. AUC have been successfully implemented in the diagnosis and management of a wide range of cardiovascular disease processes. AUC have demonstrated clear potential for influencing meaningful change in practice patterns with regards to high-value, high-quality care in cardiovascular pathologies. Potential for similar impact in the management of peripheral artery disease, specifically for patients presenting with intermittent claudication (IC), may be limited due to unique challenges. These challenges include multidisciplinary interventionalists, variability in existing AUC across specialties, and financial incentives influencing physician behavior. AUC serve to benefit patients by improving outcomes, and adoption of AUC is a critical step toward improving the quality of care provided to patients with IC. Societal support is necessary for effective AUC implementation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology., Methods: Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently., Results: Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable., Conclusion: Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care., (© 2024 Wiley Periodicals LLC.)