Dietary protein intake and health-related outcomes: a methodological protocol for the evidence evaluation and the outline of an evidence to decision framework underlying the evidence-based guideline of the German Nutrition Society

Purpose The present work aimed to delineate (i) a revised protocol according to recent methodological developments in evidence generation, to (ii) describe its interpretation, the assessment of the overall certainty of evidence and to (iii) outline an Evidence to Decision framework for deriving an evidence-based guideline on quantitative and qualitative aspects of dietary protein intake. Methods A methodological protocol to systematically investigate the association between dietary protein intake and several health outcomes and for deriving dietary protein intake recommendations for the primary prevention of various non-communicable diseases in the general adult population was developed. Results The developed methodological protocol relies on umbrella reviews including systematic reviews with or without meta-analyses. Systematic literature searches in three databases will be performed for each health-related outcome. The methodological quality of all selected systematic reviews will be evaluated using a modified version of AMSTAR 2, and the outcome-specific certainty of evidence for systematic reviews with or without meta-analysis will be assessed with NutriGrade. The general outline of the Evidence to Decision framework foresees that recommendations in the derived guideline will be given based on the overall certainty of evidence as well as on additional criteria such as sustainability. Conclusion The methodological protocol permits a systematic evaluation of published systematic reviews on dietary protein intake and its association with selected health-related outcomes. An Evidence to Decision framework will be the basis for the overall conclusions and the resulting recommendations for dietary protein intake.

Evidence-Based Decision Support for a Structured Care Program on Polypharmacy in Multimorbidity: A Guideline Upgrade Based on a Realist Synthesis

Evidence-based clinical guidelines generally consider single conditions, and rarely multimorbidity. We developed an evidence-based guideline for a structured care program to manage polypharmacy in multimorbidity by using a realist synthesis to update the German polypharmacy guideline including the following five methods: formal prioritization in focus groups; systematic guideline review of evidence-based multimorbidity/polypharmacy guidelines; evidence search/synthesis and recommendation development; multidisciplinary consent of recommendations; feasibility test of updated guideline. We identified the need for a better description of the target group, decision support, prioritization of medication, consideration of patient preferences and anticholinergic properties, and of healthcare interfaces. We conducted a systematic guideline review of eight guidelines and extracted and synthesized recommendations using the Ariadne principles. We also included 48 systematic reviews. We formulated and agreed upon 34 recommendations for the revised guideline. During the feasibility test, guideline use enabled 57% of GPs to identify problems, leading to medication changes in 49% and self-assessed improvement in 56% of patients. Although 58% of GPs felt that it was too long, 92% recommended it. Polypharmacy should be systematically reviewed at least annually. Patients, family members, and healthcare professionals should monitor and adjust it using prospective process validation, taking into account patient preferences and agreed treatment goals.

Making shoulder pain simple in general practice: implementing an evidence-based guideline for shoulder pain, protocol for a hybrid design stepped-wedge cluster randomised study (EASIER study)

IntroductionResearch suggests that current care for shoulder pain is not in line with the best available evidence. This project aims to assess the effectiveness, cost-effectiveness and the implementation of an evidence-based guideline for shoulder pain in general practice in Norway.Methods and analysisA stepped-wedge, cluster-randomised trial with a hybrid design assessing clinical effectiveness, cost-effectiveness and the effect of the implementation strategy of a guideline-based intervention in general practice. We will recruit at least 36 general practitioners (GPs) and randomise the time of cross-over from treatment as usual to the implemented intervention. The intervention includes an educational outreach visit to the GPs, a computerised decision tool for GPs and a self-management application for patients. We will measure outcomes at patient and GP levels using self-report questionnaires, focus group interviews and register based data. The primary outcome measure is the patient-reported Shoulder Pain and Disability Index measured at 12 weeks. Secondary outcomes include the EuroQol Quality of Life Measure (EQ5D-5L), direct and indirect costs, patient’s global perceived effect of treatment outcome, Pain Self-Efficacy and Brief Illness Perception Questionnaire. We will evaluate the implementation process with focus on adherence to guideline treatment. We will do a cost–minimisation analysis based on direct and selected indirect costs and a cost–utility analysis based on EQ5D-5L. We will use mixed effect models to analyse primary and secondary outcomes.Ethics and disseminationEthics approval was granted by the Regional Committee for Medical and Health Research Ethics-South East Norway (ref. no: 2019/104). Trial results will be submitted for publication in a peer-reviewed medical journal in accordance with Consolidated Standards of Reporting Trials.Trial registration numberNCT04806191.

How does discrimination occur in hospitality and tourism services, and what shall we do? A critical literature review

Purpose This study aims to critically review the research on the phenomenon of discrimination in hospitality and tourism services to identify the key thematic areas, scenarios, antecedents and consequences; to provide theoretical propositions for future research; and to propose practical strategies to reduce discrimination and to improve equality in the field. Design/methodology/approach This paper adopts the preferred reporting items for systematic reviews and meta-analyses guidelines to collect relevant academic work on discrimination in hospitality and tourism services from 1985 to 2020 and critically reviews and analyses the studies through bibliometric analysis, content analysis and critical analysis. Findings The findings show that the main sources of discrimination in hospitality and tourism services include sexism, racism, ethnocentrism, lookism and ego-altruism. Discrimination-related research has temporal and geographical variations. A research map is proposed to present existing knowledge of discrimination in hospitality and tourism services, which indicates that while the impacts (at the individual, organizational and institutional levels) of discrimination in hospitality and tourism services have been thoroughly researched, the nature and characteristics of the phenomenon remain context-based and poorly conceptualized. Practical implications An anti-discrimination guideline for hospitality and tourism practitioners is designed to cope with and eliminate discriminatory situations. This evidence-based guideline provides useful coping strategies based on the prevent–monitor–manage principle. Originality/value This paper is comprehensive in its scope, methodology and wide coverage of discrimination-related research in hospitality and tourism services. It is the first attempt to review this phenomenon in the existing literature and identifies the research gaps and future research agendas.

Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy

Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.

Development and Implementation of an Evidence-Based Guideline for Spinal Cord Injury/Disorder Patients Requiring Colonoscopy

Practice Problem: Colorectal cancer is one of the leading causes of preventable cancer death in the United States. Spinal cord injury/disorder (SCI/D) patients present with unique challenges for maximizing bowel prep and successful attainment of screening and therapeutic colonoscopy procedures. Current practice for bowel prep regimen does not take into consideration the specific needs of the SCI/D population resulting in significant patient dissatisfaction. PICOT: The PICOT question that guided this project was in adult patients with spinal cord injuries/disorders requiring colonoscopy (P), how does the development and implementation of evidence-based guideline for the care of the spinal cord injury/disorder patient requiring colonoscopy (I) compared to usual practice (C) affect the rate of first attempt successful colonoscopy procedure completion (O) within eight weeks (T). Evidence: SCI/D patients resulting neurogenic bowel increases difficulty with standard bowel prep tolerance. Quality bowel preparation is required for successful colonoscopy with inadequate bowel preparations present in 20-25% of all colonoscopies (Johnson et al., 2014). Evidence supports a clinical guideline for bowel preparation adapted to the needs of the SCI/D population. Intervention: Development and implementation of an SCI/D bowel prep guideline enhanced clinical decision support and evidence-based tools for improved bowel prep with initial attempt. Outcome: The rate of first-time colonoscopies for patients with SCI/D with the guideline improved by over 214% over pre-guideline time. Conclusion: The evidenced-based guideline reinforced clinical practice for the SCI/D population related to their unique requirements. Clinically significant improvement was noted in successful bowel prep completion, first attempt colonoscopy completion, improved access to the endoscopy suite, and reduced length of stay. All combined improved both patient and provider satisfaction with the evidence-based practice change.

COVID-19 in children: an approach for multisystem inflammatory syndrome

Background and objectives Children suffering from coronavirus disease (COVID-19) usually present with mild symptoms and show lower mortality rates than adults. However, there have been several recent reports of more severe hyperinflammatory presentation in pediatric COVID-19 patients. This review article aims to summarize the current literature available on the main clinical features and management approaches of multisystem inflammatory syndrome in children (MIS-C). Methods The authors searched different indexing databases for observational and interventional studies using search terms including “Coronavirus, COVID-19, pediatric, MIS-C, Kawasaki, and inflammation.” The retrieved publications were further assessed for relevance to the topic. Only relevant articles were included in writing this review article. Main body Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory syndrome temporally related to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in pediatrics. It is characterized by persistent fever, rash, elevated inflammatory markers, and multiorgan failure with increasing rates of cardiovascular and gastrointestinal involvement. The exact pathophysiologic mechanisms of MIS-C are still unknown, but it is postulated to be due to an exaggerated immune response to SARS-CoV-2 infection. Multisystem inflammatory syndrome in children is diagnosed by exclusion of other underlying causes of organ failure. There is a lack of clinical evidence on the management of MIS-C. The current guidelines depend mainly on expert opinion based on the management of other hyper-inflammatory syndromes in children. Patients suffering from MIS-C are treated with intravenous immunoglobulin (IVIg), corticosteroids, infliximab, tocilizumab, and anakinra. Conclusions Despite the growing reports on COVID-19 in children, there is still a lot to elucidate on the pathophysiology, diagnosis, and subsequent management of MIS-C. Further trials are needed to investigate new approaches to manage MIS-C. Specific evidence-based guideline for management of MIS-C should be tailored to the current available information on MIS-C.

Evaluation of Evidence-Based Interventions for the Nurse Coach Scope of Practice Within the Omaha System Guidelines Corpus

The purpose of this study was to examine nurse coach scope of practice in relation to existing evidence-based guideline interventions using the Omaha System. The majority of interventions were within scope for nurse coach practice, and problem, category, and target terms showed differential nurse coach practice applicability across interventions. The Omaha System terminology was aligned with nurse coach practice in that both represent and employ comprehensive and holistic perspectives. This study provides a platform for multiple initiatives in nurse coach quality and documentation and provides a methodology for examining the Omaha System guidelines and interventions for other interprofessional roles.