clinical practice guidelines

Advanced stages of dementia interfere with elderly self‑care. Consequently, they need caregivers who take responsibility for their care in the long‑term. Restrictions to the caregiver’s access to information, resources, and organizational support have created problems in their caregiver role, which is why the World Health Organization (WHO) emphasizes caring for caregivers by providing evidence‑based information and training programs. As there is no clinical practice guideline for home care in the Islamic Republic of Iran, this study aims to develop a home health care guideline for the elderly with dementia.

The ADAPTE process provided by the Guidelines International Network was considered as the basis. In order to identify the care needs of Iranian patients with dementia, semi‑structured interviews were added to this guideline.

The identification and implementation of the perspectives of patients and caregivers during the process of guidelines adaptation increase the applicability of the guidelines. Improved quality of life for the patients in their place of residence is one of the expected consequences of this guideline’s implementation. The developed guidelines will be used at home health care centers, and dementia and Alzheimer’s associations in Iran.

Clinical Practice Guidelines (CPGs) can be adapted to local conditions to prevent any resources from being wasted. Adaptation of CPGs implies a systematic view of developed guidelines through maintaining evidence-based principles in order to find the ones most relevant with patients' conditions and its integration with the cultural and regional requirements of the target population and health system facilities. The main purpose of the study was to describe, interpret and compare different frameworks for adaptation of clinical guidelines and proposing a comprehensive framework for Iran.  

This study was based on a review and comparative analysis of adaptation frameworks of CPGs. Initially, all adaptation frameworks were collected by systematic search in the literature. We searched the following electronic databases: PubMed, Scopus, Trip Database, Science Direct, and Google Scholar. Then, based on the stages of the comparative study, frameworks were described, interpreted, juxtaposed, and compared. Finally, a comprehensive framework for the adaptation of clinical guidelines was proposed by consulting a panel of experts.  

Our literature search resulted in 26 frameworks, of which 18 were potentially relevant. Based on inclusion/exclusion criteria, nine frameworks were included in the study and have been described, interpreted, and compared. The proposed comprehensive framework for the adaptation of clinical guidelines consists of ten main steps.  

The proposed comprehensive framework is an appropriate tool for the adaptation of clinical guidelines in Iran that can be used in other countries. However, further validation of the framework requires case studies and expert consultation to determine its application to the adaptation of clinical guidelines.

Developing a clinical practice guideline (CPG) is very time-consuming, expensive, and requires specialized knowledge; therefore, when an up-to-date and quality CPG is available, it is logical to adapt it according to local conditions. So this study aimed to identify the challenges of CPGs adaptation in Iran to help improve it and provide lessons for low and middle-income countries (LMICs).  

This was a qualitative study that was conducted in 2019. Semi-structured interviews were conducted with 17 participants from two levels, groups involved in the CPGs adaptation process, from research centers and specialized medical associations and policymakers and planners in CPG development and adaptation from the Ministry of Health and Medical Education (MoHME).   

The identified challenges were classified into two basic and operational categories. Basic challenges include believing the need for CPGs adaptation, attention to CPGs adaptation in evaluation and reward systems, access to financial resources, and supervision of the adaptation process. Also, operational challenges were adaptation methodology, forming an adaptation team, consensus on interdisciplinary issues, changing programs and priorities, and external barriers in the work progress path.  

The main challenges of CPGs adaptation in Iran, as one of the LMICs, are related to education, financing, and supervision of adaptation process steps. The most significant proposed interventions to overcome the current obstacles in countries with similar contexts are holding new training courses and programs for these CPG users at different headquarters' and environmental levels, establishing an appropriate motivating system, designing an integrated adaptation system focusing on organizing related supervision affairs like planning, policy-making, and supervision at the MoHME and universities level.

The pandemic coronavirus disease 2019 or COVID-19 is infecting as fast as possible in more than 200 countries and creating the most horrible domino-like demolition ever seen. From its beginning in Wuhan, China, the SARS-CoV-2 infected the similar groups of 100,000 patients in 67, 11, 4, and 2 days. Healthcare workers are in the frontline of attacking by SARS-CoV-2, especially those who are in close contact with upper respiratory mucosa like otolaryngologists.

To describe ear pain as one of the first clinical manifestations of COVID-19, we present two cases of a family (a mother and her daughter) with a positive RT-PCR test for COVID-19 who presented earache as their first symptoms.

The first case was a 32 years old female patient (stewardess of an international airline, Tehran, Iran) was labeled as at risk due to her air flight to China in Dec 2019. She was first admitted for moderate ear pain in her left ear with mild itching of the external ear to an otolaryngology outpatient clinic by a general practitioner. After 7 days, her test for RT-PCR against COVID-19 was positive. No lung involvement was reported by high-resolution computed tomography (HRCT) of the thorax. Another case was her mother who were in close contact with each other and experienced severe ear pain after 7 days. She acquired mild COVID-19 symptoms with anosmia was a positive test result for COVID-19.

The earache must be considered as their first clinical symptoms during the early phase of the coronavirus outbreak. It seems that local and international scientific groups of otolaryngologists must prepare their national guidelines to protect their practitioners against COVID-19 based on practical strategies. Using personal protective equipment is of utmost importance in reducing the risk of nosocomial infection among otolaryngologists.

Many prevalent disorders were observed in and around the knee joint. Magnetic resonance imaging (MRI) was a modern and costly diagnostic technology that was progressively applied worldwide. This study was conducted in the Bushehr educational hospitals in 2018 with the purpose of determining the necessity of knee MRI prescriptions.

This paper was a kind of cross-sectional descriptive-analytical study. The statistical population of the study was all patients who were prescribed knee MRI due to the appearance of knee problems and referred to the MRI Center of Bushehr University of Medical Sciences in 2018. The sampling method was convenient sampling. The sample in this study included 274 patients. The indications and data collection form of Vojdani et al.'s study were used to specify the necessity of the mentioned prescriptions. In this study, SPSS 22 software was applied to analyze data. Also, the Chi-Square test was used to for analyzing the data.

Among the total studied population in this study, MRI prescription was evaluated inappropriately for approximately 24 % of patients. In this study, the appropriateness of the prescriptions had a significant relationship with age, job, education level, physician prescribing, and requesting MRI (P-value < 0.05).

It could be deduced that about a quarter of MRI was not appropriate to clinical prescription. Regarding the high cost of hospital and the necessity of their reduction, induced demand would be prevented by using valid indications. Therefore, reducing unnecessary prescriptions yielded to fewer costs of the health system and patients.

This study aimed to evaluate the effectiveness of debate as a learning tool for changing audiences’ views regarding the use of clinical guidelines in routine clinical practice.

A debate scenario including different rationales for and against using guidelines in clinical practice, presented by the student section of Iranian Evidence Based Medicine Center of Excellence, was held at the first International Student Congress of Research Integrity and Evidence-Based Practice (Kish Island, Iran, December, 2015). The audience was first asked to check the papers given to them, and if they agreed to the terms, they were asked to choose,"Yes", "No", or "I don’t know".

Of the 400 individuals participating in the congress, 100 were present during the scheduled debate time. Among the 71 people completing pretest questionnaires, 73% (52)answered "yes" to the question, "Should we use guidelines? "About 7% (5) claimed that we shouldn’t use guidelines, and 20% (14) had no opinion about using them. Following the debate,the participants who chose "yes" to the guidelines remained in favor of their use in clinical practice. Of the 14 who did not have an opinion for guideline use, all agreed to use guidelines in clinical practice. Surprisingly, the five participants who were against guideline implementation remained fixed in their view, continuing to disagree regarding their use in clinical encounters.

Although we were unable to change the attitudes of physicians who were against the use of guidelines in clinical practice, the debate caused a positive shift among participants who did not have an opinion regarding their use in clinical scenarios.

Improvement of the quality ofcancer-related fatigue clinical practice guidelines (CPGs) is an important issue in oncology. This study aimed to determine the methodological quality of CPGs about cancer-related fatigue management using the AGREE II instrument. This study involved a systematic search, followed by a descriptive study, to evaluate the methodological quality of CPGs about CRF using the AGREE II instrument in 2018. A comprehensive search was conducted on different websites and databases to find the eligible published guidelines from the observation time to Jan 2018. After screening the guidelines based on eligibility criteria, the selected CPGs were assessed by five independent appraisers by means of the updated AGREE II instrument developed in 2013. According to the results, applicability and editorial independence domains had obtained low quality scores. However, the scores of the rest of the domains were indicative of a favorable quality level. Implications for Practice: It is essential to improve the quality of CRF CPGs and design high-quality CPGs especially in terms of applicability and editorial independence domains.

Evidence Based Medicine can be define as the process of systematically finding, critically appraising, and using recently published researches as a basis for making decisions regarding individual patients.One of the most prevalent MRI procedures is Brian MRI. This study aimed to identifying and developing appropriate indications for prescriptions of Brain MRI in Iran.
This is a consensus based study using one of the practical methods, RAND Appropriateness Method. The study sample were among experts in the treatment and diagnostic field of brain disorders. The experts consisted of nine specialists: Four neurosurgeons and five neurologists, all of whom were faculty members and worked in educational hospitals. The list of indications and scenarios sent to 9 experts for scoring. They scored the scenarios according to RAM instruction.
A total of 104 indications and scenarios were extracted. After that, Finally80scenarios fall in the category of appropriate scenarios, 20 in uncertain and4 in the category of inappropriate scenarios.
Currently a huge number of medical imaging prescriptions may be unnecessary in Iran and there is need for developing clinical practice guidelines. The findings of this study can be used for developing national guidelines, conducting research to assess whether the criteria are followed in practice and whether their application can curb the growing rate of unnecessary care in all countries. In Iran, a limited amount of resources are allocated to the health sector

Context: Oral mucositis is a common complication in patients with cancer therapy. Oral and dental care should be considered as a vital component of caring before, during and after chemotherapy. This study aimed to assess the methodological quality of existing CPGs about cancer therapy-induced mucositis.
Evidence Acquisition: We conducted a review of extant CPGs for the management of mucositis. After screening the guidelines based on inclusion and exclusion criteria, three CPGs were selected and assessed by 5 appraisers by using AGREE II instrument.
Assessed CPGs gained the highest scores in the clarity of the presentation domain. Scope, purpose (median score, 63.3%), and stakeholder involvement (median score, 54.4%) were found respectively and the lowest scores were in editorial independence domain. The scores in applicability (median score, 30%), rigor of development (median score, 28.8%), and editorial independence (median score, 26.7%) domains were unfavorable. Also, every appraiser scored the overall quality of CPGs.
Quality of mucositis CPGs needs to be improved. In other words, designing high-quality CPGs in this area is necessary.

Knowledge of clinical practice guidelines for Implantable Cardioverter Defibrillator (ICD) therapy is a pre-requisite for effective application of this life-saving technology. The level of trainee familiarity with these guidelines is unknown. The objective of this study was to assess trainee familiarity with clinical practice guidelines for ICD therapy.
This study surveyed 32 clinicians of varying training levels in internal medicine and cardiology at a large VA medical center. This is a survey study conducted from a population of all trainees in internal medicine at the medical center; the sample included trainees from PGY-1 through PGY-7 as well as attending physicians in internal medicine. Analysis of the collected survey data was performed using either Chi-square tests for comparison of categorical variables or unpaired t-tests for
comparison of means.
Of all respondents, 69% reported that they were familiar with published guidelines, and consistent with previously published data. Cardiologists were significantly more likely to report familiarity than internists (85% vs 42%, P=0.01). Most respondents (75%) reported satisfactory or better knowledge of published guidelines, though only 34% self-reported their knowledge as good or very good. The majority of respondents (86%) underestimated the usual cost of ICD implantation, while most respondents (78%) agreed that implantation of an ICD was cost-effective for secondary prevention, cardiologists were far more likely to agree than internists (95% vs. 50%, P There are considerable knowledge gaps evident among trainees with regard to clinical practice guidelines for ICD therapy. This likely represents a modifiable barrier to ICD implantation. Structured education for medical trainees on the appropriate use and referral practices consistent with practice guidelines may reduce knowledge gaps and increase appropriate ICD implantation.

To develop clinical practice guidelines (CPGs) for prevention, diagnosis, treatment and follow‑up of ocular injuries caused by exposure to mustard gas.
The clinical questions were designed by the guideline team. Websites and databases including National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane, and PubMed were searched to find related CPGs and explore possible answers to the clinical questions. Since there were no relevant CPGs in the literature, related articles in Persian and English languages were extracted. Each article along with its level of evidence was summarized. Additionally, hand search was performed by looking the reference list of each article. Consequently, recommendations were developed considering the clinical benefits and side effects of each therapeutic modality. The recommendations were re‑evaluated in terms of customization criteria. All recommendations along with the related evidence were scored from 1 to 9 by experts from all medical universities of Iran. The level of agreement among the experts was evaluated by analyzing the given scores.
The agreement was achieved for all recommendations. The experts suggested a number of minor modifications which were applied to the recommendations. Finally, CPGs were developed with 98 recommendations under three major domains including prevention of injury, diagnosis and management of the acute and delayed‑onset mustard gas ocular injuries.
Considering the lack of CPGs for the prevention, diagnosis, and management of mustard gas‑induced keratitis, these recommendations would be useful to prevent the serious ocular complications of mustard gas and standardize eye care services to the affected individuals.

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.
Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above‑mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.
Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.
This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

Albumin is an expensive protein colloidal solution with various indications, especially in critically ill patients. The vast use of albumin in health care centers (particularly ICUs), the theoretical danger of contaminant transmission (as with any blood derivative), and the existence of more economical alternatives of equal efficacy evidence the importance of conducting a drug-utilization evaluation. The objective of this study was to assess the usage of albumin in patients at a hospital in Iran.
Albumin administration was evaluated in 210 patients from different wards on randomly selected days during one year. Reasons for the prescription, the consumed dose, length of administration, and related laboratory tests were recorded.
Albumin was prescribed inappropriately in 76.2% and appropriately in 23.8% of inpatients. The most frequent inappropriate prescribing motives were hypoalbuminemia (35.6%), nutritional support (32.5%), and edema (24.4%), while the most appropriate prescriptions were edema (46%), nephrotic syndrome (18%), and plasmapheresis (16%). The total amount of albumin used for 210 patients was 68930 g, from which 51290 g costing $274607.1429 was administered for inappropriate indications.
Despite the many valid guidelines defining the appropriate indications of albumin, this study demonstrated the extensive inappropriate use of this expensive preparation in one of the largest university-affiliated hospitals in northwestern Iran. It seems advisable to have the consumption of albumin continuously monitored.

Clinical Practice guidelines (CPGs) have emerged as a potentially effective intervention in delivering a high quality, consistent, safe and evidence-based health care. CPGs can either be developed by de novo synthesis or by adaptation of existing guidelines formed in another organization. Guideline recommendations are formulated based on strength of the evidence, validity, clinical relevance and patient values. Support of the organization leadership, role modeling of senior staff and involvement of stakeholders is a key to the success of implementation of guidelines. This article aims to enhance a practicing pediatrician's understanding of how guidelines are developed, disseminated, and potentially utilized.