Transparent Development of the WHO Rapid Advice Guidelines Exercise for people with cancer: a clinical practice guideline. The Canadian National Breast Screening Study: responses to controversy. Outcomes and process evaluation of a programme integrating physical activity into the primary school mathematics curriculum: The EASY Minds pilot randomised controlled trial. Everything I know about informatics, I didn't learn in nursing school. A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Canadian physicians' attitudes about and preferences regarding clinical practice guidelines. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. From PALSA PLUS to PALM PLUS: adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi Balanced: a randomised trial examining the efficacy of two self-monitoring methods for an app-based multi-behaviour intervention to improve physical activity, sitting and sleep in adults Research priorities for child and adolescent physical activity and sedentary behaviours: an international perspective using a twin-panel Delphi procedure ‘On Your Feet to Earn Your Seat’, a habit-based intervention to reduce sedentary behaviour in older adults: study protocol for a randomized controlled trial Standardized Reporting of Clinical Practice Guidelines: A Proposal from the Conference on Guideline Standardization Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Methods for Development of the European Commission Initiative on Breast Cancer Guidelines China national lung cancer screening guideline with low-dose computed tomography (2015 version) Impact of early parenteral nutrition completing enteral nutrition in adult critically ill patients (EPaNIC trial): a study protocol and statistical analysis plan for a randomized controlled trial Compliance with physical activity guidelines in a group of UK-based postal workers using an objective monitoring technique Compliance with the Australian national physical activity guidelines for children: relationship to overweight status. How active are our children? Findings from the Millennium Cohort Study
Emerging health problems require rapid advice . We describe the development and pilot testing of a systematic , transparent approach used by the World Health Organization ( WHO ) to develop rapid advice guidelines in response to requests from member states confronted with uncertainty about the pharmacological management of avian influenza A ( H5N1 ) virus infection . We first search ed for systematic review s of r and omized trials of treatment and prevention of seasonal influenza and for non-trial evidence on H5N1 infection , including case reports and animal and in vitro studies . A panel of clinical experts , clinicians with experience in treating patients with H5N1 , influenza research ers , and method ologists was convened for a two-day meeting . Panel members review ed the evidence prior to the meeting and agreed on the process . It took one month to put together a team to prepare the evidence profiles ( i.e. , summaries of the evidence on important clinical and policy questions ) , and it took the team only five weeks to prepare and revise the evidence profiles and to prepare draft guidelines prior to the panel meeting . A draft manuscript for publication was prepared within 10 days following the panel meeting . Strengths of the process include its transparency and the short amount of time used to prepare these WHO guidelines . The process could be improved by shortening the time required to commission evidence profiles . Further development is needed to facilitate stakeholder involvement , and evaluate and ensure the guideline 's usefulness BACKGROUND Development of this guideline was undertaken by the Exercise for People with Cancer Guideline Development Group , a group organized by Cancer Care Ontario 's Program in Evidence -Based Care ( pebc ) . The purpose of the guideline was to provide guidance for clinicians with respect to exercise for patients living with cancer , focusing on the benefits of specific types of exercise , recommendations about screening requirements for new referrals , and safety concerns . METHODS Consistent with the pebc 's st and ardized approach , a systematic search was conducted for existing guidelines , and systematic literature search es were performed in medline and embase for both systematic review s and primary literature . Content and methodology experts performed an internal review , which was followed by an external review by targeted experts and intended users . RESULTS The search identified three guidelines , eighteen systematic review s , and twenty-nine r and omized controlled trials with relevance to the topic . The present guideline provides recommendations for the duration , frequency , and intensity of exercise appropriate for people living with cancer . It also provides recommendations for pre-exercise assessment , safety concerns , and delivery models . CONCLUSIONS There is sufficient evidence to show that exercise provides benefits in quality of life and muscular and aerobic fitness for people with cancer both during and after treatment , and that it does not cause harm . The present guideline is intended to support the Canadian Society for Exercise Physiology 's Canadian physical activity guidelines . The recommendations are intended for clinicians and institutions treating cancer patients in Ontario , and for policymakers and program planners involved in the delivery of exercise programs for cancer patients A t least since 1985 , there has been concern in some quarters that the Canadian National Breast Screening Study ( NBSS ) results 1'2 would fail to show a benefit from combined mammographic and clinical screening for breast cancer in women age 40 - 49 years . In the United States , in the spring of 1992 , the controversy about the benefits of screening women age 40 - 49 for the early detection of breast cancer erupted in the media . 3 - 7 The center of attention was the unpublished results of the NBSS . However , the center of controversy is the conflicting guidelines on breast screening for women age 40 - 49 . The very familiar guidelines of the American Cancer Society and the American College of Radiology ( ACR ) exhort women in this age group to " do themselves a favor " and get a mammogram . Although a number of prestigious professional associations have chosen to endorse these guidelines , others have not , including the US Preventive Services Task Force , the American College of Physicians , the Canadian Workshop Group , 8 the National Cancer Institute of Canada , an expert panel in the United Kingdom , 9 and the European Group for Breast Screening . 1 ° To underst and the nature of the controversy , it is helpful to review both the NBSS and published evidence from other screening studies . The Canadian NBSS was design ed to answer two major questions J , 2 First , in women age 40 - 49 , does annual mammography combined with annual physical examination of the breast for 3 or 4 years reduce the mortality rate from breast cancer as compared with a single physical examination alone ? Second , in women age 50 - 59 , how much does mammography contribute to mortality reduction over and above that achieved by physical examination alone when the comparison is annual mammography combined with physical examination versus annual physical examination alone ? The NBSS screened 89,835 women at 15 centers across Canada from 1980 - 1988 , with each woman individually r and omized to the mammography arm or the nonmammography arm of the study . Approximately 50,000 participants were 40 - 49 on entry and the remainder were 50 - 59 years of age . To be eligible , women were required to sign informed consent forms , to never have had a diagnosis of breast cancer , © 1992 by The Jacobs Institute of Women ' s Health 1049 - OBJECTIVES This study evaluated the feasibility of the ' Encouraging Activity to Stimulate Young ( EASY ) Minds ' programme , a school-based intervention for integrating physical activity ( PA ) into mathematics lessons . DESIGN R and omised controlled trial . METHODS Two classes from a single school ( n = 54 ) were r and omised to receive either the 6-week EASY Minds intervention ( n = 27 ) or follow their usual school programme ( n = 27 ) . The intervention involved the embedding of PA across the pre-existing mathematics programme for 3 × 60 min sessions per week  . Changes in PA were measured using accelerometers and ' on task ' behaviour was measured using momentary time sampling observation . RESULTS Using intention-to-treat analysis , significant intervention effects were found for MVPA ( 9.7 % , 95%CI = 7.6 , 11.8 , p ≤ 0.001 ) and sedentary time ( -22.4 % , CI = -24.9 , -12.2 , p ≤ 0.001 ) for the intervention group during Mathematics lessons ( 9.30 am-10.30 am ) . Significant intervention effects were also shown for MVPA 8.7 % ( 95 % CI = 5.8 , 11.6 , p ≤ 0.001 and sedentary time -18.6 % ( 95 % CI = -24.9 , -12.2 , p ≤ 0.001 ) across the whole school day . Furthermore , children displayed significantly greater ' on-task ' behaviour across the intervention period with a 19.9 % ( 95%CI = 2.4 , 37.4 , p ≤ 0.03 ) mean difference between groups . CONCLUSIONS The EASY Minds programme demonstrated that integrating movement across the primary mathematics syllabus is feasible and efficacious in enhancing school based-PA and improving on-task behaviour in mathematics lessons To date , efforts to initiate future graduates and nurses currently in practice into the world of information and communication technologies ( ICTs ) have been provided by relatively few nurse educators . In the past decade , nursing informatics leaders have developed a profile of informatics competencies for nurses , novice to expert – for example , the National Nursing Informatics Project ( Hebert 2000 ) – and have demonstrated actual ( Kaminski 2006 ) and possible informatics integration into curricula ( Nagle 2001 ) . Findings from recent studies ( Infoway 2007 ; Nagle and Clarke 2004 ) suggest that a minority of Canadian schools of nursing have tackled the challenge of integrating informatics throughout their nursing curricula . When asked to respond to a recent survey ( Infoway 2007 ) , some schools decided not to participate because there were no faculty members with appropriate expertise in the area , while other schools did not regard informatics as relevant content for their program . Nevertheless , over the years , several schools of nursing have had the foresight to create a single informatics course – usually an elective – at the undergraduate or graduate level . I have held discussion s with several deans and directors of schools of nursing over the past two years , and most of them recognize that this is a content area to be reckoned with sooner rather than later . No graduate nursing program has , as yet , created an informatics specialty option , but stay tuned . An Academic/Learning Advisory Group was recently created as a key component of Infoway ’s user engagement strategy . Since many of the core informatics concepts can be addressed interprofessionally , this group includes academics , students and practitioners from health informatics , nursing , medicine and pharmacy . The m and ate of this advisory group is to provide input to the development of strategies and tactics to support ( a ) continuous professional development for clinicians in practice in the use of electronic health record solutions ( EHRs ) and ( b ) the integration of informatics Everything I Know About Informatics , I Did n’t Learn in Nursing School Lynn M. Nagle Electronic Healthcare Vol . 6 No. 4 Online Exclusive 2008 2 content into the core curricula of the health disciplines . The advisory group members bring knowledge from the academic and healthcare delivery arenas and expertise in informatics , e-learning and knowledge translation . The group has been working on the development of a conceptual framework that will be used to underpin the direction of subsequent work . Infoway ’s future efforts will include the capture of success stories and exemplars of successful EHR training and informatics integration in work environments and basic training programs . To date , an environmental scan has been undertaken in the hope of obtaining representative sample s of schools of nursing , medicine and pharmacy . Additionally , recent graduates were asked to participate in a survey of perceived readiness for the workplace in relation to the use of ICTs . Unfortunately , the response rates to both surveys were insufficient to yield any meaningful conclusions . Unless there has been a dramatic upturn in the integration of informatics among schools of nursing , one might assume that the findings from the 2003 Canadian Nursing Informatics Association ( Nagle and Clarke 2004 ) study of 79 schools of nursing are likely still a reflection of the status quo . That study showed that less than 40 % of the schools had addressed or integrated informatics content . I suspect that there is still much work to be done . So where to begin ? Within healthcare organizations , there are now many experiences in the field with successful and failed implementations . What is well known is the importance of user engagement from the outset of any EHR initiative . What is yet unknown is the effectiveness of the various models and strategies being used within healthcare organizations to get practitioners engaged , educated and trained in the use of EHR applications . Based upon personal experience and discussion with many colleagues across Canada , educators in healthcare organizations need • multiple and flexible methods and tools for delivery , • knowledge of adult learning principles and • credibility among their peers . “ Expert user ” does not equate to “ educator . ” Clinician users want • sustained support post-implementation , • engaged leadership and • extended opportunities to develop a comfort level with applications . These are simple concepts , touted by many as key success factors , but they are not always evident . Among the many challenges within healthcare organizations is not only skillful integration of ICTs with existing practice s , but also sufficient time to educate and train an already overtaxed workforce . Implementation ultimately comes down to the perceived value of the EHR tools to support clinical care delivery effectively – no value , no buy-in , no commitment to learn and use . Canadian schools of nursing are of the highest calibre in the world ; faculty are renowned worldwide for their programs of research and publications . Many are even conducting leading-edge research in the informatics realm . Whether recognized or not , in today ’s Everything I Know About Informatics , I Did n’t Learn in Nursing School Lynn M. Nagle Electronic Healthcare Vol . 6 No. 4 Online Exclusive 2008 3 world , informatics is simply a part of every faculty member ’s tool kit . Therefore , it should not be offered or developed as a separate course . Rather , it should be integrated with approaches to the theoretical and practical teachings in every course . A student nurse recently lamented to me that his class was told they could not use electronic textbooks because of faculty discomfort with the medium . Today ’s students want their texts available on a h and held device ; they want to use technology in their learning and practice . Educators need to encourage the integration of technology , underst and the use and potential of EHRs and become champions in their own right . Otherwise , I fear we run the risk of discouraging the prospect i ve technology-savvy student from pursuing a career in nursing . Hopefully , unlike my generation , nursing students and graduates of the future will know enough about informatics to position themselves in the emerging clinical world of ICTs . While writing this article , I reflected upon the related contributions of the late Dr. Pat Griffin to this work . As executive director of the Canadian Association of Schools of Nursing ( CASN ) and a member of the Infoway Nursing Advisory Group , Pat brought thoughtful insights and her commitment to our discussion s about engaging nurse educators in the informatics agenda . She was a self-procl aim ed “ nontechy , ” telephoning me in recent months to confess abashedly that she had misplaced my e-mail address – “ it would have to be you , of all people ! ” Nonetheless , she recognized the importance of addressing the delivery of informatics knowledge and skills to nurses . In fact , the week prior to her death , she participated in her usual whole-hearted way in an all-day meeting of the advisory group and was planning for my participation in the CASN board meeting the following week . In her memory , I encourage all educators of nurses to boldly embrace this challenge ! About the Author Lynn M. Nagle , RN , PhD , is a senior nursing advisor with Canada Health Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals . The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism . The mission of SCCM is to secure the highest quality care for all critically ill and injured patients . Guideline Limitations : These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who , in developing such guidelines , have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy . However , practice guidelines are not intended as absolute requirements . The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival . The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines . The guidelines offer basic recommendations that are supported by review and analysis of the current literature , other national and international guidelines , and a blend of expert opinion and clinical practicality . The population of critically ill patients in an intensive care unit ( ICU ) is not homogeneous . Many of the studies on which the guidelines are based are limited by sample size , patient heterogeneity , variability in disease severity , lack of baseline nutritional status , and insufficient statistical power for analysis . Periodic Guideline Review and Up date : This particular report is an up date and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 ( 1 ) . Governing bodies of both A.S.P.E.N. and SCCM have m and ated that these guidelines be up date d every three to five years . The data base of r and omized controlled trials ( RCTs ) that served as the platform for the analysis of the literature was assembled in a joint “ harmonization process ” with the Canadian Clinical Guidelines group . Once completed , each group operated separately in their interpretation of the studies and derivation of guideline recommendations ( 2 ) . The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature search es by the authors through December 31 , 2013 . Although the committee was aware of l and mark studies published after this date , these data were not included in this manuscript . The process by which the literature was evaluated necessitated a common end date for the search review . Adding a last-minute l and mark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript . Target Patient Population for Guideline : The target of these guidelines is intended to be the adult ( ≥ 18 years ) critically ill patient expected to require a length of stay ( LOS ) greater than 2 or 3 days in a medical ICU ( MICU ) or surgical ICU ( SICU ) . The current guidelines were exp and ed to include a number of additional subsets of patients who met the above criteria , but were not included in the previous 2009 guidelines . Specific patient population s addressed by these exp and ed and up date d guidelines include organ failure ( pulmonary , renal , and liver ) , acute pancreatitis , surgical subsets ( trauma , traumatic brain injury [ TBI ] , open abdomen [ OA ] , and burns ) , sepsis , postoperative major surgery , chronic critically ill , and critically ill obese . These guidelines are directed toward generalized patient population s but , like any other management strategy in the ICU , nutrition therapy should be tailored to the individual patient . Target Audience : The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill , primarily physicians , nurses , dietitians , and pharmacists . Methodology : The authors compiled clinical questions reflecting key management issues in nutrition therapy . A committee of multidisciplinary experts in clinical nutrition composed of physicians , nurses , pharmacists , and dietitians was jointly convened by the two societies OBJECTIVE To assess Canadian physicians '  confidence in , attitudes about and preferences regarding clinical practice guidelines . DESIGN Cross-sectional , self-administered mailed survey . PARTICIPANTS Stratified r and om sample of 3000 Canadian physicians ; 1878 ( 62.6 % ) responded . SETTING Canada . OUTCOME MEASURES Physicians ' use of various information sources ; familiarity with and confidence in guidelines ; attitudes about guidelines and their effect on medical care ; rating of importance of guidelines and other sources of information in clinical decision-making ; rating of importance of various considerations in deciding whether to adopt a set of guidelines ; and rating of usefulness of different formats for presenting guidelines . MAIN RESULTS In all , 52 % of the respondents reported using guidelines at least monthly , substantially less frequently than traditional information sources . Most of the respondents expressed confidence in guidelines issued by various physician organizations , but 51 % to 77 % were not confident in guidelines issued by federal or provincial health ministries or by health insurance plans . The respondents were generally positive about guidelines ( e.g. , over 50 % strongly agreed that they are a convenient source of advice and good educational tools ) ; however , 22 % to 26 % had concerns about loss of autonomy , the rigidity of guidelines and decreased satisfaction with medical practice . Endorsement by respected colleagues or major organizations was identified as very important by 78 % and 62 % of the respondents respectively in deciding whether to adopt a set of guidelines in their practice . User friendliness of the guidelines format was thought to be very important by 62 % ; short pamphlets , manuals summarizing a number of guidelines , journal articles and pocket cards summarizing guidelines were the preferred formats ( identified as most useful by 50 % to 62 % of the respondents ) . CONCLUSIONS Canadian physicians , although generally positive about guidelines and confident in those developed by clinicians , have not yet integrated the use of guidelines into their practice s to a large extent . Our results suggest that respected organizations and opinion leaders should be involved in the development of guidelines and that the acceptability of any proposed format and medium for guidelines presentation should be pretested BACKGROUND In 2010 , the Canadian Thoracic Society ( CTS ) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older , and adults , including an up date d Asthma Management Continuum . The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline up date process , focusing , in this first iteration , on topics of controversy and ⁄or gaps in the previous guidelines . METHODS Four clinical questions were identified as a focus for the up date d guideline : the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy ; the initiation of adjunct therapy to inhaled corticosteroids ( ICS ) for uncontrolled asthma ; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever , and as a reliever and a controller ; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan . The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics . In addition , literature search es were performed to identify relevant systematic review s and r and omized controlled trials . The panel formally assessed and grade d the evidence , and made 34 recommendations . RESULTS The up date d guideline recommendations outline a role for inclusion of assessment of sputum eosinophils , in addition to st and ard measures of asthma control , to guide adjustment of controller therapy in adults with moderate to severe asthma . Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations . New recommendations for the adjustment of controller medication within written action plans are provided . Finally , priority areas for future research were identified . CONCLUSIONS The present clinical practice guideline is the first up date of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee 's new guideline development process . Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide up date s reflecting new evidence Background Only about one-third of eligible HIV/AIDS patients receive anti-retroviral treatment ( ART ) . De central izing treatment is crucial to wider and more equitable access , but key obstacles are a shortage of trained healthcare workers ( HCW ) and challenges integrating HIV/AIDS care with other primary care . This report describes the development of a guideline and training program ( PALM PLUS ) design ed to integrate HIV/AIDS care with other primary care in Malawi .  PALM PLUS was adapted from PALSA PLUS , developed in South Africa , and targets middle-cadre HCWs ( clinical officers , nurses , and medical assistants ) . We adapted it to align with Malawi 's national treatment protocol s , more varied healthcare workforce , and weaker health system infrastructure . Methods / Design The international research team included the developers of the PALSA PLUS program , key Malawi-based team members and personnel from national and district level Ministry of Health ( MoH ) , professional associations , and an international non-governmental organization . The PALSA PLUS guideline was extensively revised based on Malawi national disease-specific guidelines . Advice and input was sought from local clinical experts , including middle-cadre personnel , as well as Malawi MoH personnel and representatives of Malawian professional associations . Results An integrated guideline adapted to Malawian protocol s for adults with respiratory conditions , HIV/AIDS , tuberculosis , and other primary care conditions was developed . The training program was adapted to Malawi 's health system and district-level supervision structure . PALM PLUS is currently being piloted in a cluster-r and omized trial in health centers in Malawi ( IS RCT N47805230 ) . Discussion The PALM PLUS guideline and training intervention targets primary care middle-cadre HCWs with the objective of improving HCW satisfaction and retention , and the quality of patient care . Successful adaptations are feasible , even across health systems as different as those of South Africa and Malawi Background Many adults are insufficiently physically active , have prolonged sedentary behaviour and report poor sleep . These behaviours can be improved by interventions that include education , goal setting , self-monitoring , and feedback strategies . Few interventions have explicitly targeted these behaviours simultaneously or examined the relative efficacy of different self-monitoring methods . Methods / Design This study aims to compare the efficacy of two self-monitoring methods in an app-based multi-behaviour intervention to improve objective ly measured physical activity , sedentary , and sleep behaviours , in a 9 week 2–arm r and omised trial . Participants will be adults ( n = 64 ) who report being physically inactive , sitting > 8 h/day and frequent insufficient sleep ( ≥14 days out of last 30 ) . The “ Balanced ” intervention is delivered via a smartphone ‘ app ’ , and includes education material s ( guidelines , strategies to promote change in behaviour ) , goal setting , self-monitoring and feedback support . Participants will be r and omly allocated to either a device-entered or user-entered self-monitoring method . The device-entered group will be provided with a activity tracker to self-monitor behaviours . The user-entered group will recall and manually record behaviours . Assessment s will be conducted at 0 , 3 , 6 , and 9 weeks . Physical activity , sedentary behaviour and sleep-wake behaviours will be measured using the wrist worn Geneactiv accelerometer . Linear mixed models will be used to examine differences between groups and over time using an alpha of 0.01 . Discussion This study will evaluate an app-based multi-behavioural intervention to improve physical activity , sedentary behaviour and sleep ; and the relative efficacy of two different approaches to self-monitoring these behaviours . Outcomes will provide information to inform future interventions and self-monitoring targeting these behaviours . Trial registration ACTRN12615000182594 ( Australian New Zeal and Clinical Trials Registry . Registry URL : www.anzctr.org.au ; registered prospect ively on 25 February 2015 ) Background The quantity and quality of studies in child and adolescent physical activity and sedentary behaviour have rapidly increased , but research directions are often pursued in a reactive and uncoordinated manner . Aim To arrive at an international consensus on research priorities in the area of child and adolescent physical activity and sedentary behaviour . Methods Two independent panels , each consisting of 12 experts , undertook three rounds of a Delphi methodology . The Delphi methodology required experts to anonymously answer questions put forward by the research ers with feedback provided between each round . Results The primary outcome of the study was a ranked set of 29 research priorities that aim ed to be applicable for the next 10 years . The top three ranked priorities were : developing effective and sustainable interventions to increase children ’s physical activity long-term ; policy and /or environmental change and their influence on children ’s physical activity and sedentary behaviour ; and prospect i ve , longitudinal studies of the independent effects of physical activity and sedentary behaviour on health . Conclusions These research priorities can help to guide decisions on future research directions Background Many older adults are both highly sedentary ( that is , spend considerable amounts of time sitting ) and physically inactive ( that is , do little physical activity ) . This protocol describes an exploratory trial of a theory-based behaviour change intervention in the form of a booklet outlining simple activities ( ‘ tips ’ ) design ed both to reduce sedentary behaviour and to increase physical activity in older adults . The intervention is based on the ‘ habit formation ’ model , which proposes that consistent repetition leads to behaviour becoming automatic , sustaining activity gains over time . Methods The intervention is being developed iteratively , in line with Medical Research Council complex intervention guidelines . Selection of activity tips was informed by semi-structured interviews and focus groups with older adults , and input from a multidisciplinary expert panel . An ongoing preliminary field test of acceptability among 25 older adults will inform further refinement . An exploratory r and omized controlled trial will be conducted within a primary care setting , comparing the tips booklet with a control fact sheet . Retired , inactive and sedentary adults ( n = 120 ) aged 60 to 74 years , with no physical impairments precluding light physical activity , will be recruited from general practice s in north London , UK . The primary outcomes are recruitment and attrition rates . Secondary outcomes are changes in behaviour , habit , health and wellbeing over 12 weeks . Discussion Data will be used to inform study procedures for a future , larger-scale definitive r and omized controlled trial . Trial registration Current Controlled Trials IS RCT N47901994 Evidence -based clinical practice guidelines can reduce the delivery of inappropriate care and support the introduction of new knowledge into clinical practice ( 1 - 3 ) . In many cases , guidelines encapsulate the most current knowledge about best practice s. Rigorously developed guidelines can translate complicated research findings into actionable recommendations for clinical care ( 4 ) . Over the past decade , a plethora of guidelines has been created and published by a multitude of organizations at substantial cost . Despite the enormous energies invested in guideline authoring , the quality of individual guidelines varies considerably . In its l and mark report , the Institute of Medicine ( IOM ) defined 8 desirable attributes of clinical practice guidelines : validity , reliability and reproducibility , clinical applicability , clinical flexibility , clarity , documentation , development by a multidisciplinary process , and plans for review ( 5 ) . However , critical information that would attest to validity or would document fulfillment of the other IOM criteria is regularly absent from published guidelines . In an evaluation of 279 guidelines developed by U.S. medical specialty societies , Shaneyfelt and colleagues ( 6 ) found that guidelines published in the peer- review ed medical literature do not adhere to established method ologic st and ards . Likewise , Grilli and colleagues ( 7 ) found that of 431 guidelines produced by specialty societies , 82 % did not apply explicit criteria to grade the scientific evidence that supported their recommendations , 87 % did not report whether a systematic literature search was performed , and 67 % did not describe the type of professionals involved in guideline development . Systematic review s of guidelines for drug therapy ( 8) , management of depression ( 9 ) , and osteoporosis ( 10 ) have confirmed marked variation in quality . Both nonadherence to method ologic st and ards and failure to document development activities contribute to this variation . We convened the Conference on Guideline St and ardization ( COGS ) to define a st and ard for guideline reporting that would promote guideline quality and facilitate implementation . The proposed st and ard provides a checklist of components necessary for evaluation of validity and usability . The checklist is intended to minimize the quality defects that arise from failure to include essential information and to promote development of recommendation statements that are more easily implemented . In contrast to other instruments that have been developed for post hoc evaluation of guideline quality , the COGS checklist is intended to be used prospect ively by developers to improve their product by improving documentation . The COGS panel used a systematic and rigorous process to define content of the proposed st and ard and to achieve consensus . The COGS panel also included a wide variety of perspectives , deliberately bringing together representatives from medical specialty societies , government agencies , and private groups that develop guidelines ; journal editors and the National Guideline Clearinghouse ( NGC ) , which disseminate guidelines ; guideline implementers , including managed care representatives and informaticians ; and academicians . Methods We actively sought people with diverse background s from wide-ranging geographic areas to participate in the meeting . Selection criteria for participants were 1 ) activity in a wide variety of guidelines initiatives , 2 ) recognition as leaders in their field , and 3 ) willingness to collaborate . To maximize interaction , the number of participants in the Conference was limited . We set as a task for the panelists the specification and definition of a set of necessary guideline components that should be considered for reporting in all evidence -based practice guidelines . We defined necessary items as those that establish the validity of the guideline recommendations or facilitate practical application of the recommendations . We noted that many additional items might be considered appropriate components in guidelines , but sought to define a minimal set of essential elements . We assembled a list of c and i date guideline components from the IOM Provisional Instrument for Assessing Clinical Guidelines ( 5 ) , the NGC ( 11 ) , and the Guideline Elements Model ( 12 ) , a hierarchical model of guideline content that was created from a systematic review of published guideline descriptions . These items were supplemented with items highlighted in the literature , for example , structured abstract ( 13 ) and conflict of interest ( 14 ) . We applied a modified Delphi approach to help focus group discussion . This approach has been widely applied for evaluation of expert opinion on appropriateness ( 15 ) and medical necessity ( 16 ) , for policy development ( 17 ) , and for prioritization ( 18 ) . The technique has been described in detail ( 19 ) . In brief , after we secured agreement to participate in the COGS panel , we gave all participants a bibliography of re sources regarding guideline quality and its appraisal , guideline implementation , and the modified Delphi consensus development approach . Panelists were asked to rate their agreement with the statement that [ Item name ] is a necessary component of practice guidelines on a 9-point scale . Rating an item with a 9 indicated strong agreement with the statement that this item was necessary . Rating an item with a 1 indicated strong disagreement with the statement and suggested that the item was absolutely unnecessary in a guideline . A rating of 5 indicated neutrality or indifference . We developed a password-protected Web site that panelists used to complete the first round of ratings online before the meeting . Online rating permitted accurate and efficient data capture and analysis . For each item , the median rating and the disagreement index ( defined as the Interpercentile Range divided by the Interpercentile Range Adjusted for Symmetry ) were calculated ( 19 ) . The disagreement index , which can be calculated for panels of any size , describes the dispersion of ratings more effectively than the mean absolute deviation from the median . Index values greater than 1 indicate disagreement . We displayed summary statistics for each item on a form that was individualized for each panelist . The COGS meeting was held on 26 and 27 April 2002 in New Haven , Connecticut . In a colloquy facilitated by 2 of the authors , each c and i date item was discussed to ensure that all participants agreed on its definition and potential contribution to the COGS checklist and to highlight empirical evidence of its value . When appropriate , additional items were added to the list . The group determined that in the second round of ratings , it would be valuable to rate each item 's necessity on 2 subscales : necessity to establish validity and necessity for practical application . The participants then rated each item on these 2 dimensions . Analysis We tallied the median score and the disagreement index for each item . We retained items with median scores of 7 or higher and disagreement indexes less than 1.0 on either scale as necessary guideline components on the checklist . To interpret necessity , the 9-point scale is divided into 3 ranges : items scoring 1 to 3 are considered unnecessary , items scoring 4 to 6 are neutral , and items scoring 7 to 9 are considered necessary ( 20 ) . In this study , the threshold of 7 was chosen because it represented the lowest rating at which the participants indicated that an item was necessary for inclusion in guidelines . Pilot Review To field test the proposed checklist , we surveyed organizations that were active in guideline development . We identified all organizations that met the NGC Web site criteria for guideline display on 12 July 2002 . From that list , we selected organizations that had developed 10 or more guidelines displayed on the NGC Web site . We excluded 1 ) organizations that participated in development of the COGS checklist [ because of potential bias ] and 2 ) government agencies and organizations based outside the United States ( for logistic reasons ) . A draft COGS checklist and a brief survey were sent to the people identified as being responsible for guideline development at each eligible organization . Results All 23 panelists su bmi tted first- and second-round ballots . During the discussion , participants suggested consideration of 10 new items in the second round of balloting and refined definitions of several items . Thirty-six discrete items were considered necessary to establish guideline validity ; they received ratings of 7 or greater and had disagreement indexes of less than 1 . Twenty-four items were considered necessary for practical application of the guideline , each with a disagreement index less than 1 . Several items were rated necessary on both dimensions . Overall , 44 discrete items were considered necessary . Closely related items were then consoli date d into 18 topics to create the COGS checklist for reporting clinical guidelines ( Table ) . Appendix Tables 1 and 2 present a complete listing of all items rated and their scores . Table . The COGS Checklist for Reporting Clinical Practice Guidelines Appendix Table 1 . Items Ranked Necessary for Guideline Validity , Median Ratings , Distribution of Ratings by Tertiles , and Disagreement Index Appendix Table 2 . Items Ranked Necessary for Guideline Usability , Median Ratings , Distribution of Ratings by Tertiles , and Disagreement Index Twenty-two organizations met eligibility criteria for evaluation of the draft checklist , and all completed the survey ( 100 % response rate ) . Sixteen organizations ( 73 % ) responded that they believed the checklist would be helpful for creating more comprehensive practice guidelines , and an additional 2 organizations ( 9 % ) responded that it might be helpful . Nineteen respondents ( 86 % ) indicated that documenting the proposed items would fit within their organizations ' guideline development methods . Fifteen ( 68 % ) stated that they would use the proposed checklist in guideline OBJECTIVE This study was conducted to develop evidence -based clinical practice guidelines for nutrition support ( ie , enteral and parenteral nutrition ) in mechanically ventilated critically ill adults . OPTIONS The following interventions were systematic ally review ed for inclusion in the guidelines : enteral nutrition ( EN ) versus parenteral nutrition ( PN ) , early versus late EN , dose of EN , composition of EN ( protein , carbohydrates , lipids , immune-enhancing additives ) , strategies to optimize delivery of EN and minimize risks ( ie , rate of advancement , checking residuals , use of bedside algorithms , motility agents , small bowel versus gastric feedings , elevation of the head of the bed , closed delivery systems , probiotics , bolus administration ) , enteral nutrition in combination with supplemental PN , use of PN versus st and ard care in patients with an intact gastrointestinal tract , dose of PN and composition of PN ( protein , carbohydrates , IV lipids , additives , vitamins , trace elements , immune enhancing substances ) , and the use of intensive insulin therapy . OUTCOMES The outcomes considered were mortality ( intensive care unit [ ICU ] , hospital , and long-term ) , length of stay ( ICU and hospital ) , quality of life , and specific complications . EVIDENCE We systematic ally search ed MEDLINE and CINAHL ( cumulative index to nursing and allied health ) , EMBASE , and the Cochrane Library for r and omized controlled trials and meta-analyses of r and omized controlled trials that evaluated any form of nutrition support in critically ill adults . We also search ed reference lists and personal files , considering all articles published or unpublished available by August 2002 . Each included study was critically appraised in duplicate using a st and ard scoring system . VALUES For each intervention , we considered the validity of the r and omized trials or meta-analyses , the effect size and its associated confidence intervals , the homogeneity of trial results , safety , feasibility , and the economic consequences . The context for discussion was mechanically ventilated patients in Canadian ICUs .  BENEFITS , HARMS , AND COSTS The major potential benefit from implementing these guidelines is improved clinical outcomes of critically ill patients ( reduced mortality and ICU stay ) . Potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions . SUMMARIES OF EVIDENCE AND RECOMMENDATIONS : When considering nutrition support in critically ill patients , we strongly recommend that EN be used in preference to PN . We recommend the use of a st and ard , polymeric enteral formula that is initiated within 24 to 48 hours after admission to ICU , that patients be cared for in the semirecumbent position , and that arginine-containing enteral products not be used . Strategies to optimize delivery of EN ( starting at the target rate , use of a feeding protocol using a higher threshold of gastric residuals volumes , use of motility agents , and use of small bowel feeding ) and minimize the risks of EN ( elevation of the head of the bed ) should be considered . Use of products with fish oils , borage oils , and antioxidants should be considered for patients with acute respiratory distress syndrome . A glutamine-enriched formula should be considered for patients with severe burns and trauma . When initiating EN , we strongly recommend that PN not be used in combination with EN . When PN is used , we recommend that it be supplemented with glutamine , where available . Strategies that maximize the benefit and minimize the risks of PN ( hypocaloric dose , withholding lipids , and the use of intensive insulin therapy to achieve tight glycemic control ) should be considered . There are insufficient data to generate recommendations in the following areas : use of indirect calorimetry ; optimal pH of EN  ; supplementation with trace elements , antioxidants , or fiber ; optimal mix of fats and carbohydrates ; use of closed feeding systems ; continuous versus bolus feedings ; use of probiotics ; type of lipids ; and mode of lipid delivery . VALIDATION This guideline was peer- review ed and endorsed by official representatives of the Canadian Critical Care Society , Canadian Critical Care Trials Group , Dietitians of Canada , Canadian Association of Critical Care Nurses , and the Canadian Society for Clinical Nutrition . SPONSORS This guideline is a joint venture of the Canadian Critical Care Society , the Canadian Critical Trials Group , the Canadian Society for Clinical Nutrition , and Dietitians of Canada . The Canadian Critical Care Society and the Institute of Nutrition , Metabolism , and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline Critically ill patients in the intensive care unit ( ICU ) are at high risk for infections associated with increased morbidity , mortality , and health care costs ( 1 - 3 ) . The overall infection rate in critically ill patients approaches 40 % and may be as high as 50 % or 60 % in patients who remain in the ICU for more than 5 days ( 4 , 5 ) . Respiratory tract infections account for 30 % to 60 % of all such infections . The incidence of pneumonia acquired in the ICU ranges from 10 % to 65 % ( 6 - 11 ) . Among patients at high risk for ventilator-associated pneumonia ( VAP ) are those who have chronic obstructive pulmonary disease , burns , neurosurgical conditions , the acute respiratory distress syndrome , and witnessed aspiration ; those who are reintubated ; and those who receive paralytic agents or enteral nutrition ( 12 , 13 ) . The attributable morbidity and mortality of VAP are clinical ly important . In a prospect i ve , matched cohort study , patients with VAP remained in the ICU 4.3 days ( 95 % CI , 1.5 to 7.0 days ) longer than patients who did not have VAP and had a trend toward an increased risk for death ( absolute risk increase , 5.8 % [ CI , 2.4 % to 14.0 % ] ) ( 14 ) . Six other studies using a matching strategy found a prolonged length of ICU stay associated with VAP ( range , 5 to 13 days ) and attributable mortality ranging from an absolute risk increase of 0 % to 50 % ( 15 - 20 ) . Therefore , strategies to decrease the incidence of VAP could decrease morbidity , mortality , and health care costs and improve patient safety . A survey of the use of VAP prevention strategies identified differences across countries ( 21 ) . For example , changing the ventilator circuit for each new patient was reported more frequently by French ICU directors than those in Canada ( 21 ) . This survey also showed that some effective strategies were used infrequently , suggesting inadequate translation of r and omized trial results into practice . One potential catalyst for knowledge translation is an evidence -based clinical practice guideline . Therefore , a Joint Planning Group of the Canadian Critical Care Society and Canadian Critical Care Trials Group commissioned the development of an evidence -based clinical practice guideline for the prevention of VAP . In this paper , we describe the methods used to create the guideline and the recommendations generated . Methods The Joint Planning Group selected an 11-member VAP Prevention Guideline Panel made up of 9 intensivists from university-affiliated and community hospitals , an ICU nurse , and an ICU respiratory therapist . Panel members were experts in critical care medicine ( n= 9 ) , VAP ( n= 4 ) , evidence -based medicine ( n= 4 ) , and guideline development ( n= 3 ) . The context was mechanically ventilated adult patients cared for in the ICU . The target audience was ICU clinicians in university-affiliated and community hospitals . To identify potentially relevant evidence , we search ed 3 bibliographic data bases ( MEDLINE , EMBASE , and the Cochrane Data base of Systematic Review s ) to 1 April 2003 for r and omized trials that evaluated interventions influencing VAP ( Appendix ) . We had no language restrictions . We also review ed personal files and practice guidelines on this subject previously published by the Centers for Disease Control and Prevention ( 22 ) and the American Thoracic Society ( 23 ) . We included r and omized trials and systematic review s of r and omized trials that 1 ) studied adult critically ill patients ; 2 ) had VAP as an outcome ; and 3 ) evaluated any of the following interventions : physical strategies ( route of endotracheal intubation , systematic search for maxillary sinusitis , frequency of ventilator circuit changes , type of airway humidification , frequency of humidifier changes , endotracheal suctioning system , subglottic secretion drainage , chest physiotherapy , and tracheostomy timing ) , positional strategies ( kinetic beds , semi-recumbent positioning , and prone positioning ) , and pharmacologic strategies ( stress ulcer prophylaxis and prophylactic antibiotics , including selective decontamination of the digestive tract ) . Since study authors used various definitions of VAP , we used the definitions they provided . The most common definition was a new or persistent radiographic infiltrate plus fever , leukocytosis , change in the volume or color of sputum , or isolation of a pathogen . If available , histologic evidence of pneumonia was also used . A priori , we decided to review only systematic review s of r and omized clinical trials for antibiotic prophylaxis and only r and omized clinical trials for all other topics . We excluded crossover and beforeafter studies . We also excluded r and omized trials of ventilator weaning , including noninvasive mechanical ventilation , and nutritional interventions evaluating VAP because guidelines addressing these topics have recently been published ( 24 , 25 ) . In duplicate and independently , 3 pairs of panel members critically appraised each trial ( 26 , 27 ) and systematic review ( 28 ) . Each member of a pair compared his or her independent appraisal of a given trial or systematic review with that of the other member of the pair . For each r and omized trial , we abstract ed sample , allocation , intervention , co- interventions , exclusions after r and omization , blinding of outcome assessment , definition of VAP , crude VAP events , relative risk for VAP , and other outcomes . For each intervention , we summarized the risk differences and calculated a pooled risk difference . For each systematic review , we abstract ed number of trials , population , intervention , selection criteria , search strategy , validity assessment , method of pooling results , homogeneity assessment , VAP definition , pooled event rates , and other outcomes . Before the panel meeting , each pair of appraisers achieved consensus on the validity and results of the trials they review ed . One month before the panel meeting , panel members received the evidence tables for review prepared by the 3 pairs of appraisers . A priori , panel members agreed to read all circulated documents and evidence tables in advance , to use levels of evidence to generate a status statement for each item , and to abide by the group process and consensus methods . The Canadian Critical Care Society appointed a chair to ensure that the panel achieved its objectives through group process ( 29 ) . At the panel meeting , each member recorded any potential conflicts of interest ( 30 ) . The pair of panel members responsible for critical appraisal of each intervention provided a structured written and oral presentation of the evidence . After the panel discussion , the initial evidence summary was revised if necessary . The panel members assigned levels of evidence , semi-quantitative scores to summarize the evidence and describe the intervention , and a status statement . We classified trials as level 1 if they had all of the following : concealed r and omization , blinded outcome adjudication , an intention-to-treat analysis , and an explicit definition of VAP . Trials were classified as level 2 if any one of these characteristics was unfulfilled and as level 3 if allocation was not strictly r and omized . We used a semi-quantitative score ( 0 , 1 , 2 , or 3 ) to evaluate each intervention with respect to the validity of the r and omized trials ; the effect size of each intervention ; the confidence intervals around the estimate of effect ; the homogeneity of the trial results ; and the safety , feasibility , and economic consequences of the intervention . The language of the status statement for each item was keyed to the levels of evidence and the semi-quantitative scores . We used the term recommended if there were no reservations about endorsing an intervention and the term considered if the evidence supported an intervention but there were minor uncertainties about the benefits , harms , or costs . No recommendation was made if evidence regarding an intervention was inadequate or if there were major uncertainties about the benefits , harms , or costs . After the panel meeting , the chair compiled the summaries and status statements and sent them to all panel members to check accuracy and clarity . In addition , the pairs of evidence appraisers wrote background documents for the interventions they appraised , including the rationale for each intervention , appraisal of r and omized trials and systematic review s , and harms and costs of the interventions . The chair and the writing committee organized the background documents , the evidence summaries , a table of the semi-quantitative scores , and the status statement for each item . We formatted the document with a structured abstract ( 31 ) , a summary of the evidentiary basis for each recommendation , and a status statement for each item . We also created a quick reference guide . The draft guideline document was su bmi tted for structured external review by the executives of the Canadian Critical Care Society and the Canadian Critical Care Trials Group and the respective executives of the Canadian Association of Critical Care Nurses , Canadian Society of Respiratory Therapists , Canadian Infectious Disease Society , and Canadian Thoracic Society . External review ers were asked to critique whether the guideline was logical , clear , and practical and to critique the guideline development process . The panel revised the document on the basis of this feedback . The final guideline was returned to the external review ers for further comments and official endorsement by their respective organizations . The final guideline was then piloted in 2 institutions . To record the agreement of each panel member with the final status statement for each item , we sent the final document to all panel members . Independently , blinded to each other 's ratings , panel members used a Likert scale from 1 to 9 that was anchored by disagree completely at the low end and agree completely at the high end . The panel will formally review and up date this guideline every 2 years ( 32 ) . The funding source played no role in study selection for this guideline and had no role in its The Canadian Thoracic Society ( CTS ) guidelines for the diagnosis and treatment of sleep disordered breathing in adults were developed over the past year . A one-day meeting was held in Montreal , Quebec , on October 28 , 2005 , just before the annual CTS meeting . The meeting was facilitated by Dr R Davies ( Oxford , United Kingdom ) , and speakers included D Morrison ( Halifax , Nova Scotia ) , J Kimoff ( Montreal ) , J Fleetham ( Vancouver , British Columbia ) , C George ( London , Ontario ) , M Kryger ( Winnipeg , Manitoba ) , P Hanly ( Calgary , Alberta ) , F Hill ( Saskatoon , Saskatchewan ) , D Bradley ( Toronto , Ontario ) , N Ayas ( Vancouver ) , M Fitzpatrick ( Kingston , Ontario ) , F Series ( Quebec City , Quebec ) , K Ferguson ( London ) and W Tsai ( Calgary ) . This meeting was attended by 28 Canadian physicians with an interest in sleep disordered breathing . A draft of an Executive Summary was developed , and then review ed and finalized by the CTS Sleep Disordered Breathing Committee at a one-day meeting in Toronto on February 17 , 2006 . The Committee members then individually ranked the level of evidence as : grade A – high- quality meta- analysis or single r and omized clinical trial ( RCT ) that had a low risk of bias ; grade B – high- quality systematic review of cohort studies or single cohort study with a low risk of bias or extrapolated evidence from high- quality RCTs or RCTs with a risk of bias ; grade C – case-control studies or cohort studies with a risk of bias ; or grade D – case series , case reports or expert opinion . The Committee members also ranked their agreement with each statement ( strongly agree , agree , neutral , disagree or strongly disagree ) . No statement was included unless at least 90 % of the Committee either strongly agreed or agreed with it In December 2003 , the European Council identified best practice as key for ensuring development of high- quality cancer-screening programs . To support national policies on cancer control , the European Union institutions progressed several initiatives on cancer . The European Commission ( EC ) Initiative on Breast Cancer ( ECIBC ) is the most recent of these projects and the most implementation driven . Within this initiative , the European Guidelines for Breast Cancer Screening and Diagnosis ( in short , European Breast Guidelines ) are being developed ( http://ecibc.jrc.ec.europa.eu/ ) . Guidelines are approaches to generally improve prevention , diagnosis , treatment , and follow-up of diseases , overcoming inappropriate variations by providing recommendations for best care . The new era of guidelines promises recommendations that are based on the best available evidence summarized in systematic review s while providing the necessary flexibility needed to individualize decisions . The best methods for development of practice guidelines have experienced intense elaboration and attention during the past decades ( 17 ) . The impetus for this attention has been the change from expert- or consensus-based to evidence -based health care recommendations . Although this change in terminology should express the shift from un systematic development of guidelines to systematic and trustworthy recommendations , it is often misunderstood and misconstrued as meaning that experts are now meaningless in the process or as if consensus through discussion is a matter of the past . Neither is correct . Experts from various disciplines and consensus as a result of deliberation remain a mainstay of health care guideline development ( 810 ) . These experts are responsible for prioritization of questions that should be addressed in guidelines ; judgments that result from interpretation of evidence , including the rating of the certainty of the available evidence ; and decisions about how the judgments on the different criteria bear on recommendations . What has changed over time in guideline development are the rules , the structure and explicitness of the process , and the guideline product . Indeed , review s of guideline development methodology and how guidelines can be improved have led to more structured and documented processes that allow a reduction of bias and provide balanced views of appropriately composed guideline panels ( 2 , 5 , 6 ) . Core components for trustworthy guideline development ( 13 , 5 , 7 , 11 ) include that guidelines be developed by a knowledgeable , multidisciplinary panel of experts and representatives from key affected groups ; be based on a systematic review of the existing evidence ; consider important patient subgroups and patient preferences as appropriate ; be based on an explicit and transparent process that minimizes distortions , biases , and conflicts of interest ( 12 ) ; provide a clear explanation of the logical relationships between alternative care options and health outcomes and provide ratings of both the quality of evidence and the strength of the recommendations ( 1316 ) ; and be reconsidered and revised as appropriate when important new evidence warrants modifications . In addition , greater transparency in linking the considered research evidence and the recommendations , as well as the requirement of making structured expert judgments , represents a shift in the guideline development paradigm ( 5 , 11 , 1719 ) . At the same time , developing guidelines for a large number of member states and those that aim to adapt the guidelines poses challenges , such as the feasibility of implementing strategies that may exist in some member countries but not others ( for example , organized population -based screening in Italy but not Greece ) . Addressing these challenges requires considerations that extend beyond strictly clinical efforts in guideline development and mastering the many factors that influence recommendations and their implementation . This article describes the rationale , methods , and processes the ECIBC has adopted to develop the European Breast Guidelines in the context of evolving international st and ards . It also describes an innovative approach to presenting , disseminating , and accelerating implementation of recommendations . Guideline Methodology and Development To adhere to the core requirements for guideline development , the EC has taken several steps . First , it selected , via an open call ( https://ecibc.jrc.ec.europa.eu/ guidelines -team ) , a panel with broad representation of expertise , knowledge , and background , which includes patients , health care professionals , epidemiologists , guideline method ologists , and others ( Appendix ) . These individuals voluntarily participate in the ECIBC and compose the guidelines development group ( GDG ) . Second , it ensured that all recommendations were supported by systematic review s of the evidence conducted by independent scientists from Cochrane Iberoamricathe systematic review team (SRT)following st and ard Cochrane Collaboration methods ( 20 , 21 ) . Third , because this is a women-centered initiative , we included women advocates in the GDG as full voting guideline group members . We separately considered important subgroups of women during recommendation development ( for example , different age groups ) , and we specifically focused on evidence that supports best ways of communicating this information to women to inform their decisions . Fourth , we applied EC conflict of interest rules ( http://ecibc.jrc.ec.europa.eu/rules ) , which are consistent with international recommendations , and used GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) Evidence to Decision ( EtD ) frameworks to minimize the influence of competing interests on the recommendations ( 12 , 17 , 18 ) . These EtD frameworks help guideline panels use evidence in a structured , transparent way to inform decisions with a series of criteria , such as anticipated harms and benefits of the options considered , the certainty of the evidence for those effects , and the costs and feasibility of the options , to help them reach their decision . Fifth , using the GRADE approach to guideline development and its EtD frameworks , we focused our questions and recommendations on outcomes that matter to women and provided a rating of the certainty or quality of evidence and the strength of recommendations that is widely accepted as the reference st and ard ( Figures 1 and 2 ) . Sixth , our evidence review s are up to date when the recommendations are formulated , and we engage in international stakeholder feedback to ensure that recommendations remain timely and relevant to public health and clinical practice . The ECIBC is committed to review ing and updating the recommendations as required when new evidence becomes available . The general process is explained in Figure 3 and is based on the Guidelines International NetworkMcMaster Guideline Development Checklist ( https://hei grade .mcmaster.ca/ guideline -development/using-checklist ) ( 5 ) . Figure 1 . According to GRADE , certainty , quality , strength of evidence , or confidence in the estimate of effect is determined on the basis of a systematic review of the evidence for each outcome ( based on the domains risk of bias , indirectness , imprecision , inconsistency , and publication bias that lower certainty and , usually only for nonr and omized studies , large effects , doseresponse relations and opposing plausible residual confounding that may increase the certainty ) . For recommendations , the overall certainty is determined across outcomes based on the lowest certainty outcome among those critical for decision making for the specific context . The guidelines development group applies the GRADE Evidence -to-Decision frameworks to make recommendations that are made available on the European Commission Web site . ( Reproduced from reference 15 , with permission from Schnemann HJ . ) . GRADE = Grading of Recommendations Assessment , Development and Evaluation . Figure 2 . GRADE EtD frameworks . The GRADE EtD frameworks as available in the GRADE pro software ( www . grade pro.org ) . They help with structuring the entire guideline process into 4 sections and support the conduct of guideline group meetings , presentation , and implementation . They clarify the perspective that is taken by the guideline panel or decision maker and the type of question that is asked in the question section . The section on assessment includes the criteria if the problem is a priority , the balance of health benefits and harms , values and preferences related to the outcomes , cost , re sources and cost-effectiveness , equity , acceptability , and feasibility . Conclusions provide the decision or recommendation with a justification and implementation , as well as research considerations . The presentation function supports the conduct of guideline group meetings and facilitates the output of EtD frameworks to other implementation tools , such as Web sites , h and -held apps , and interactive decision aids . EtD = Evidence to Decision ; GRADE = Grading of Recommendations Assessment , Development and Evaluation ; HTA = health technology assessment ; PICO = population , intervention , comparators , and outcomes . Figure 3 . Approach to guideline development used by the European Commission Initiative on Breast Cancer . The European Commission JRC has oversight of the organization , budgeting , planning , and training . The JRC also manages conflicts of interest , documents all aspects of the work , and manages the membership and group processes . The guideline development group and JRC formulate the questions and work with the systematic review team on identifying and assessing the evidence . The guidelines development group is responsible for developing the recommendations . The JRC is responsible for most other aspects as described in the figure under dissemination , implementation , and updating . JRC = Joint Research Centre ; PICO = population , intervention , comparator , and outcomes . ( Reproduced with adaptation to the JRC process from BACKGROUND Lung cancer is the leading cause of cancer-related death in China . Results from a r and omized controlled trial using annual low-dose computed tomography ( LDCT ) in specific high-risk groups demonstrated a 20 % reduction in lung cancer mortality . METHODS A China national lung cancer screening guideline was developed by lung cancer early detection and treatment expert group appointed by the National Health and Family Planning Commission , based on results of the National Lung Screening Trial , systematic review of evidence related to LDCT screening , and protocol of  lung cancer screening  program conducted in rural China . RESULTS Annual lung cancer screening with LDCT is recommended for high risk individuals aged 50 - 74 years who have at least a 20 pack-year smoking history and who currently smoke or have quit within the past five years . Individualized decision making should be conducted before LDCT screening . LDCT screening also represents an opportunity to educate patients as to the health risks of smoking ; thus , education should be integrated into the screening process in order to assist smoking cessation . CONCLUSIONS A lung cancer screening guideline is provided for the high-risk population in China Background For critically ill patients treated in intensive care units ( ICU ) , two feeding strategies are currently being advocated , one by American/Canadian and the other by European expert guidelines . These guidelines differ particularly in the timing of initiating parenteral nutrition ( PN ) in patients for whom enteral nutrition ( EN ) does not reach caloric targets . Methods / Design The EPaNIC trial is an investigator-initiated , non-commercial , multi-center , r and omized , controlled , clinical trial with a parallel group design . This study compares early ( European guideline ) versus late ( American/Canadian guideline ) initiation of PN when EN fails to reach a caloric target . In the early PN group , PN is initiated within 24 - 48 hours after ICU admission to complete early enteral nutrition ( EN ) up to a calculated nutritional target . In the late PN group , PN completing EN is initiated when the target is not reached on day 8 . In both groups , the same early EN protocol is applied . The study is design ed to compare clinical outcome ( morbidity and mortality ) in the 2 study arms as well as to address several mechanistical questions . We here describe the EPaNIC study protocol and the statistical analysis plan for the primary report of the clinical results . Discussion The study has been initiated as planned on august 01 2007 . One interim analysis advised continuation of the trial . The study will be completed in February 2011.Trial Registration Clinical Trials ( NCT ) : Compliance with physical activity ( PA ) recommendations was assessed using objective PA monitoring of ambulatory activity , in two healthy groups of individuals with active and sedentary occupations . The study showed generally low compliance with the guidelines ( 53 % with 10,000 steps a day ; 10 % with 30 min of moderate activity a day ; and 1 % with 30 min of moderate activity a day in bouts of at least 10 min ( ACSM ) ) . Adherence to guidelines decreased as more rigorous conditions were applied to the PA data . Use of an objective monitor revealed that health enhancing bouts of activity were performed in periods of approximately 1-min duration , which may be due to unavoidable environmental interruptions . These bouts of activity are much shorter than those advocated in the ACSM guidelines , raising questions regarding how actual behaviour , based on objective monitoring , can be reconciled with guidelines based on self-reported PA Childhood obesity incidence has increased substantially and it has been argued that decreasing physical activity levels , coinciding with an increase in sedentary behaviours , are responsible . Australian guidelines were published in 2004 , recommending that children participate in a minimum of 60 min of physical activity daily and spend no more than 2h a day using electronic media for entertainment . We aim ed to compare compliance with these guidelines amongst children of differing weight status . The Childhood Injury Prevention Study ( CHIPS ) collected data from a r and omly selected sample of Brisbane primary and preschool children aged 5 - 12 years . The following data were available for 518 participants : age , gender , measured height and weight and estimated time per week from a parent-completed 7 days diary in physical activity out of school and sedentary leisure activities including television viewing and computer use . Using age st and ardised body mass index estimates , approximately 20 % of the cohort were overweight . Non-compliance with guidelines was 14.7 % for out of school physical activity participation , and 30.9 % for excess electronic media entertainment use . There was a 63 % increase in the odds of overweight status amongst children who were non-compliant with the electronic entertainment recommendations than those who were compliant ( adjusted odds ratio=1.63 ; 95 % CI=1.05 - 2.54 ) . Female gender and school level socioeconomic category were also independently associated with overweight status . Non-compliance with the minimal physical activity guideline increased the odds of being overweight by 28 % , however this difference was not statistically significant . One in seven children from the Greater Brisbane area are at risk for being insufficiently active whilst a third overuse electronic media . Given that overuse of electronic entertainment was positively associated with childhood obesity , these children should be the target of public health campaigns to promote alternative leisure time activities Objective To describe levels of physical activity , sedentary time and adherence to Chief Medical Officers ( CMO ) physical activity guidelines among primary school-aged children across the UK using objective accelerometer-based measurements . Design Nationally representative prospect i ve cohort study . Setting Children born across the UK , between 2000 and 2002 . Participants 6497 7-year-old to 8-year-old singleton children for whom reliable accelerometer data were available for at least 10 h a day for at least 2 days . Main outcome measures Physical activity in counts per minute ( cpm ) ; time spent in sedentary and moderate-to-vigorous intensity physical activity ( MVPA ) ; proportion of children meeting CMO guidelines ( ≥60 min/day MVPA ) ; average daily steps . Explanatory measures Gender , ethnicity , maternal current/most recent occupation , lone parenthood status , number of children in the household and country/region of residence . Results The median daily physical activity level was 595 cpm ( IQR 507 , 697 ) . Children spent a median of 60 min ( IQR 47–76 ) in MVPA/day and were sedentary for a median of 6.4 h/day ( IQR 6–7 ) . Only 51 % met CMO guidelines , with girls ( 38 % ) less active than boys ( 63 % ) . Children took an average of 10 229 ( 95 % CI ( 8777 to 11 775 ) ) steps each day . Children of Indian ethnicity were significantly less active overall than all other ethnic groups . Children of Bangladeshi origin and those living in Northern Irel and were least likely to meet CMO guidelines . Conclusions Only half of 7-year-old children in the UK achieve recommended levels of physical activity , with significant gender , ethnic and geographic variations . Longitudinal studies are needed to better underst and the relevance of these (in)activity patterns for long-term health and well-being . In the meantime population -wide efforts to boost physical activity among young people are needed which are likely to require a broad range of policy interventions
Conclusions These guidelines represent a sensible evolution of public health guidelines whereby optimal health is framed within the balance of movement behaviours across the whole day , while respecting preferences of end-users .
Background The Canadian Society for Exercise Physiology convened representatives of national organizations , research experts , method ologists , stakeholders , and end-users who followed rigorous and transparent guideline development procedures to create the Canadian 24-Hour Movement Guidelines for the Early Years ( 0–4 years ) : An Integration of Physical Activity , Sedentary Behaviour , and Sleep .
These novel guidelines for children of the early years embrace the natural and intuitive integration of movement behaviours across the whole day ( 24-h period ) .