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Abstract Background Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

Abstract Background Practice guidelines can improve health care delivery and outcomes but several issues challenge guideline adoption, including their intrinsic attributes, and whether and how they are implemented. It appears that guideline format may influence accessibility and ease of use, which may overcome attitudinal barriers of guideline adoption, and appear to be important to all stakeholders. Guideline content may facilitate various forms of decision making about guideline adoption relevant to different stakeholders. Knowledge and attitudes about, and incentives and capacity for implementation on the part of guideline sponsors may influence whether and how they develop guidelines containing these features, and undertake implementation. Examination of these issues may yield opportunities to improve guideline adoption. Methods The attributes hypothesized to facilitate adoption will be expanded by thematic analysis, and quantitative and qualitative summary of the content of international guidelines for two primary care (diabetes, hypertension) and institutional care (chronic ulcer, chronic heart failure) topics. Factors that influence whether and how guidelines are implemented will be explored by qualitative analysis of interviews with individuals affiliated with guideline sponsoring agencies. Discussion Previous research examined guideline implementation by measuring rates of compliance with recommendations or associated outcomes, but this produced little insight on how the products themselves, or their implementation, could be improved. This research will establish a theoretical basis upon which to conduct experimental studies to compare the cost-effectiveness of interventions that enhance guideline development and implementation capacity. Such studies could first examine short-term outcomes predictive of guideline utilization, such as recall, attitude toward, confidence in, and adoption intention. If successful, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes could be evaluated.

The article presents a study that determines effective approaches in diagnosing fever of unknown origin (FUO). It details the method of the study that observes basic investigations and abdominal computed tomography (CT). It notes the result of the study which indicates that fair evidences supporting CT, Duke criteria, and leg Doppler imaging can effectively evaluate fever of unknown origin.

Background: Patients with lumbar disc herniation may greatly benefit from microdiscectomy. Although spine surgeons performing microdiscectomy routinely obtain informed consent, the potential adverse events they disclose often vary. Moreover, little is known about what disclosures are deemed most valuable by patients. The aim of this mixed-methods study was to determine practice variations among spine surgeons in regard to the disclosure of potential adverse events during informed consent discussions for lumbar microdiscectomy and to determine which topics patients perceived to be valuable in the consent discussion., Methods: A survey evaluating the frequency with which spine surgeons disclose 15 potential adverse events related to lumbar microdiscectomy during informed consent discussions was distributed among Canadian Spine Society members. Additionally, semistructured interviews were conducted with preoperative patients, postoperative patients, attending spine surgeons, spine fellows and orthopedic residents. Interview transcripts were analyzed using thematic analysis with open coding., Results: Fifty-one Canadian Spine Society members completed the survey. The number of potential adverse events not routinely discussed was greater among orthopedic surgeons than among neurosurgeons (relative risk 1.83; 95% confidence interval 1.22-2.73; p = 0.003). Three preoperative patients, 7 postoperative patients, 6 attending spine surgeons, 3 spine fellows and 5 orthopedic residents participated in the semistructured interviews. The interviews identified gaps in information provided to patients, particularly on topics relating to postoperative care such as expected recovery time, activity restrictions and need for a caregiver., Conclusion: There is variation in the disclosure of potential adverse events during informed consent discussions for lumbar microdiscectomy among Canadian spine surgeons. Patients desire more information regarding their postoperative care. Further research should focus on developing guidelines to reduce practice variation and optimize the effectiveness of consent discussions., Competing Interests: A. Yee is an executive member of the Canadian Spine Society. He was not involved in distributing the survey or collating the survey results. He was involved in interpreting the survey results. He reports receiving educational grants, sponsorship of his university and hospital’s spine program activities, personal fees and in-kind research support from Medtronic, outside the submitted work. He also reports receiving educational grants and sponsorship of his university and hospital’s spine program activities from Stryker, Zimmer Biomet, Johnson & Johnson and DePuy Synthes, outside the submitted work. No other competing interests declared., (© 2020 Joule Inc. or its licensors.)

The standard treatment for patients with primary antibody deficiency is immunoglobulin (IG), but the care of these patients is complex. These guidelines, initiated by the Canadian Blood Services and the National Advisory Committee on Blood and Blood Products, have been developed to facilitate and standardize the care of these patients by the various physician specialties that are responsible for their care. A panel of national expert immunologists and methodologists developed salient clinical questions; and a systematic, expert, and bibliography literature search up to July 2008 was conducted. One thousand eighty-seven citations were retrieved, and 102 reports were used in the preparation of this guideline. The recommendations provide guidance (1) on the complexity of the treatment of these patients; (2) the established benefits of IG on morbidity and mortality; (3) dosage, routes of administration, and management of reactions; (4) the various IG formulations available; (5) vaccination of these patients; and (6) research priorities.

Background: Contact dermatitis (CD) is a common occupational disease. There have been no systematic reviews of CD treatment or prevention., Methods: Multiple databases were systematically searched. Using independent double review and published quality review criteria, articles were rated as good, fair, or poor. Treatment benefit data were tabulated and conclusions were based on the rated strength of published evidence., Results: In all, 49 studies met inclusion criteria. Barrier creams containing dimethicone or perfluoropolyethers, cotton liners, and softened fabrics prevent irritant CD. Lipid-rich moisturizers both prevent and treat irritant CD. Topical skin protectant and quaternium 18 bentonite (organoclay) prevent rhus dermatitis. Diethylenetriamine pentaacetic acid (chelator) cream prevents nickel, chrome, and copper dermatitis. Potent or moderately potent steroids effectively treat allergic CD. There were no macrolide immunomodulator trials that met inclusion criteria. This review did not include studies of children, animals, or non-English language publications., Conclusions: A limited number of interventions effectively prevent or treat irritant and allergic CD, but well-controlled, outcome-blinded studies, particularly in the area of allergic CD prevention are needed.

Objective: Communication regarding end-of-life care is frequently perceived as suboptimal, despite the intent of both health care providers and patients. We interviewed health care providers to determine their perspective regarding these barriers to communication., Materials and Methods: Eleven focus groups with a total of 10 attending physicians, 24 residents, and 33 nurses were convened to explore barriers to end-of-life discussions on the Internal Medicine service at a 600-bed tertiary care hospital in Toronto, Canada. An interview schedule was designed to elicit information regarding the process of end-of-life discussions, barriers to these discussions, and possible interventions for limiting such barriers. Transcripts were qualitatively analyzed by 6 raters who independently identified "themes." Themes were refined using the Delphi technique and classified under broader "categories.", Results: Four main categories of barriers emerged, relating to (1) patients, (2) the health care system, (3) health care providers, and (4) the nature of this dialogue. Attending physicians and residents most frequently identified patient-related factors as barriers to discussions, followed by system, dialogue, and provider barriers (43%, 39%, 10%, and 8%, respectively, for attending physicians; 40%, 34%, 13%, and 13%, respectively, for residents). Nurses similarly identified patient-related and system barriers most frequently, but provider barriers were discussed more often than dialogue barriers (46%, 28%, 22%, and 4%, respectively)., Conclusions: Attending physicians, residents, and nurses perceive the recipients of their care, and the system within which they provide this care, to be the major source of barriers to communication regarding end-of-life care. This finding may impact on the effectiveness of quality-improvement initiatives in end-of-life care.

Purpose: We wanted to systematically review whether primary care-based interventions improve initiation and duration of breastfeeding., Methods: Studies were found by searching MEDLINE (1966-2001), Health-STAR, the Cochrane Database of Systematic Reviews, the National Health Service Centre for Reviews and Dissemination Databases, and bibliographies of identified trials and review articles. Studies were included if they originated in the primary care setting and were conducted in a developed country, written in English, and contained a concurrent control group., Results: Thirty randomized and nonrandomized controlled trials and 5 systematic reviews of breastfeeding counseling were included. Educational programs had the greatest effect of any single intervention on both initiation (difference 0.23; 95% confidence interval [CI], 0.12-0.34) and short-term duration (difference 0.39; 95% CI, 0.27-0.50). Support programs conducted by telephone, in person, or both increased short-term (difference 0.11; 95% CI, 0.03-0.19) and long-term duration (difference 0.08; 95% CI, 0.02-0.16). In contrast, written materials such as pamphlets did not significantly increase breastfeeding. Data were insufficient to determine whether the combination of education with support was more effective than education alone., Conclusions: Educational programs were the most effective single intervention. One woman would breast-feed for up to 3 months for every 3 to 5 women attending breastfeeding educational programs. Future research and policy should focus on translating these findings into more widespread practice in diverse primary care settings.

Background: Fever of unknown origin (FUO) is defined as a temperature higher than 38.3 degrees C on several occasions and lasting longer than 3 weeks, with a diagnosis that remains uncertain after 1 week of investigation., Methods: A systematic review was performed to develop evidence-based recommendations for the diagnostic workup of FUO. MEDLINE database was searched (January 1966 to December 2000) to identify articles related to FUO. Articles were included if the patient population met the criteria for FUO and they addressed the natural history, prognosis, or spectrum of disease or evaluated a diagnostic test in FUO. The quality of retrieved articles was rated as "good," "fair," or "poor," and sensitivity, specificity, and diagnostic yield of tests were calculated. Recommendations were made in accordance with the strength of evidence., Results: The prevalence of FUO in hospitalized patients is reported to be 2.9%. Eleven studies indicate that the spectrum of disease includes "no diagnosis" (19%), infections (28%), inflammatory diseases (21%), and malignancies (17%). Deep vein thrombosis (3%) and temporal arteritis in the elderly (16%-17%) were important considerations. Four good natural history studies indicate that most patients with undiagnosed FUO recover spontaneously (51%-100%). One fair-quality study suggested a high specificity (99%) for the diagnosis of endocarditis in FUO by applying the Duke criteria. One fair-quality study showed that computed tomographic scanning of the abdomen had a diagnostic yield of 19%. Ten studies of nuclear imaging revealed that technetium was the most promising isotope, showing a high specificity (94%), albeit low sensitivity (40%-75%) (2 fair-quality studies). Two fair-quality studies showed liver biopsy to have a high diagnostic yield (14%-17%), but with risk of harm (0.009%-0.12% death). Empiric bone marrow cultures showed a low diagnostic yield of 0% to 2% (2 fair-quality articles)., Conclusions: Diagnosis of FUO may be assisted by the Duke criteria for endocarditis, computed tomographic scan of the abdomen, nuclear scanning with a technetium-based isotope, and liver biopsy (fair to good evidence). Routine bone marrow cultures are not recommended.

Objective: To review evidence about the benefit of intensive glycemic control for patients with type 2 diabetes and to develop practice recommendations., Participants: A 9-member panel composed of family physicians, general internists, endocrinologists, and a practice guidelines methodologist was assembled by the American Academy of Family Physicians, the American Diabetes Association, and the American College of Physicians., Evidence: Admissible evidence included published randomized controlled trials and observational studies regarding the effects of glycemic control on microvascular and macrovascular complications and on adverse effects. We followed systematic search and data abstraction procedures. Greater weight was given to clinical trials and to evidence about health outcomes., Consensus Process: Interpretations of evidence and approval of documents were finalized by unanimous vote, with recommendations linked to evidence and not expert opinion. The full report was prepared by the chair and 2 panel members, representing each of the 3 organizations. The initial draft underwent external review by 14 diabetologists and family physicians and changes consistent with the evidence were incorporated., Conclusions: The evidence demonstrates that the risk of microvascular and neuropathic complications is reduced by lowering glucose concentrations. Whether glycemic control affects macrovascular outcomes is less clear. The potential benefits of glycemic control must be balanced against factors that either preempt benefits (eg, limited life expectancy, comorbid disease) or increase risk (eg, severe hypoglycemia). The magnitude of benefit is a function of individual clinical variables (eg, baseline glycated hemoglobin level, presence of preexisting microvascular disease). Appropriate targets for treatment should be determined by considering these factors, patients' risk profiles, and personal preferences.

Purpose: To summarize available evidence on preoperative cardiac risk stratification so that the internist may 1) use clinical and electrocardiographic findings to stratify a patient's perioperative risk for myocardial infarction and death; 2) decide which tests provide useful additional risk-related information; and 3) understand the benefits, risks, and evidence surrounding the decision to undertake coronary revascularization before elective noncardiac surgery., Data Sources: A MEDLINE search and review of the reference lists of identified articles. Sensitivities, specificities, and likelihood ratios for diagnostic tests were calculated, and a quality rating for study methods was applied., Data Extraction: Myocardial infarction and mortality were the major outcomes considered, and a quality rating for study methods was applied., Data Synthesis: Clinical and electrocardiographic findings, organized by multivariate prediction indices, accurately identify patients as having low, intermediate, or high risk for myocardial infarction or death. Pharmacologic stress imaging with thallium or echocardiography probably improves risk stratification for intermediate-risk patients having vascular surgery. These tests have not been shown to be effective prognostic indicators for patients having nonvascular surgery. No studies of angiography for risk prediction have been reported. Decision analyses and retrospective series suggest that the risks incurred by doing coronary angiography and revascularization before elective surgery outweigh the benefits. Prospective, controlled studies of coronary revascularization are lacking. Evidence from a randomized, controlled trial has shown a survival benefit with the perioperative use of beta-blockers in patients at risk for coronary artery disease., Conclusions: Evaluation of all surgical patients by use of clinical indices is recommended. Low-risk patients need no further evaluation before surgery. High-risk patients need optimal management of their high-risk problems, including (if appropriate) beta-blocker use, and may need to have their elective procedures canceled. Intermediate-risk patients probably benefit from further noninvasive stress testing, especially if they are having vascular surgery. Further clinical trials are needed for most areas of concern.

Purpose: To describe the change in use of tamoxifen over time and across countries in Ontario., Methods: Data from the Ontario Drug Benefit (ODB) plan, Census Canada, and the Ontario Cancer Registry (OCR) were combined and analysed to determine rates of tamoxifen use for females over 65 for each county and the province overall, by year. Rates were analyzed by repeated measures ANOVA to determine significance of changes over time. Consistency of tamoxifen use across counties was determined by the Spearman rank correlation coefficient, and overall variation between counties was described using three statistical techniques: Chi-square analysis, the extremal quotient (EQ), and the systematic component of variation (SCV)., Results: The number of one-month tamoxifen prescriptions per incident case of breast cancer rose significantly from 13.51 in 1985 to 20.54 in 1990 (p < 0.001) and to 34.06 in 1992 (p = 0.001). Viewed differently, the number of women over 65 receiving tamoxifen prescriptions per incident case of breast cancer changed from 1.91 in 1985 to 3.14 in 1990 to 4.54 in 1992. Statistically significant variation in the rate of tamoxifen prescribing was demonstrated between Ontario counties in all three years by Chi Squared analysis (p < 0.0001). Both the EQ and the SCV declined from 1985 to 1990, suggesting more uniform prescribing across the province. Little change in overall variation was seen between 1990 and 1992. All counties over time tended to prescribe generic preparations more often and shifted from 10 mg to 20 mg formulations., Conclusions: The significant increase in the rate of tamoxifen use and trend towards more uniform prescribing across Ontario between 1985 and 1990 coincided with the publication of two important documents outlining the benefits of tamoxifen in early breast cancer. Despite this trend, variation in tamoxifen use between counties remains. There has been little change in uniformity of prescribing since 1990.

Evidence is accumulating that, in vivo and in vitro, both 25-OH-D3 and 1,25-(OH)2D3 undergo side-chain modification leading to side-chain cleaved metabolites lacking the 24, 25, 26, and 27 carbons. The enzymes involved are D-dependent and are located in the kidney, bone, intestine, and perhaps other sites. We speculate that the extra-renal side-chain pathway may be primarily for target organ destruction of 1,25-(OH)2D3, whereas the renal pathway may be primarily for destruction of 25-OH-D3 formed in large amounts in hypervitaminosis D.