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Background: Analytical frameworks (AF) are graphical representation of the key questions answered by a systematic review and can support the development of guideline recommendations. Our objectives are to a) conduct a systematic review to identify, describe and compare all AFs published as part of a systematic and guideline development process related to colorectal cancer (CRC); and b) to use this case study to develop guidance on how to conduct systematic reviews of AFs. Methods: We conducted a systematic review and searched Medline and Embase from 1996 until December 2020. We also manually searched guideline databases and websites. We identified all guidelines in CRC that utilized an AFs and all systematic reviews in primary prevention, screening, and diagnosis of CRC that used AFs. We assessed quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool. The systematic review was registered in PROSPERO, registration CRD42020172117. Results: We screened 34,505 records and identified 1166 guidelines on CRC and 3127 systematic reviews, of which 5 met our inclusion criteria identifying a total of 4 AFs in colorectal cancer. We describe our search strategy and methods for conducting systematic reviews for AFs. Conclusion: Few guidelines and systematic reviews are utilizing AFs in the development of recommendations. We developed methods for conducting a systematic review on AF / Thesis / Master of Science (MSc) / Analytical frameworks are graphical diagrams that represent key questions with flow of resining from population to outcome. We conducted a systematic review to identify all analytical frameworks in colorectal cancer and in the process we developed guidance on how to conduct a systematic review for analytical frameworks. We identified four analytical frameworks, one in primary prevention, and three in screening of colorectal cancer. We found only a few clinical practice guidelines that utilized analytical frameworks in the development of the recommendations. We developed methods for conducting a systematic review of analytical frameworks.

An evidence-based clinical practice guideline was developed to prevent and manage constipation in long-term care (LTC) residents, a vulnerable population not specifically addressed in previous guidelines. A literature review was completed, and evidence was evaluated and included in initial draft recommendations. The guideline was reviewed for content validity using a Delphi committee of clinical experts in gastroenterology, geriatrics, and pharmacy. The updated guideline was presented to an interdisciplinary team that reviewed its clinical applicability. Overall, interdisciplinary team members agreed or strongly agreed the guideline was clinically applicable (n=30). Finally, the guideline was evaluated by a group of doctorally-prepared practicing nurse practitioners using the Appraisal of Guidelines for Research and Evaluation II instrument. Appraiser scores were 85% or higher in every domain, indicating the guideline was perceived as high in quality. Development of this guideline signifies an initial step in the management and prevention of constipation in LTC residents.

The purpose of this research study was to examine the current use of clinical practice by full-time occupational therapy faculty members. Clinical practice, including faculty clinical practice and moonlighting were addressed. The seven research questions addressed were: (a) the perceived benefits of clinical practice as identified by occupational therapy faculty members; (b) the perceived barriers to clinical practice as identified by occupational therapy faculty; (c) if perceived benefits and barriers of clinical practice as identified by occupational therapy faculty differ as a function of their academic institution's Carnegie Classification (The Carnegie Foundation, 2000); (d) if perceived benefits and barriers of clinical practice differ among respondents according to tenure at the institution, tenure status, doctoral degree, rank, administrative duties, and gender; (e) the incidence of clinical practice in occupational therapy faculty members; (f) the relationship between participation in clinical practice and the Carnegie classification of the occupational therapy member's academic institution; (g) the characteristics (tenure status, doctoral degree, rank, administrative duties, and gender) of faculty members that participate in clinical practice either within or outside the faculty role; and (h) the characteristics of clinical practice as described by faculty members and how these differed if the clinical practice is conducted as part of the faculty role or outside the faculty role. Data were collected using an on-line survey that contained 43 questions designed to elicit information that addressed the research questions. The surveys were electronically mailed to the population of full-time occupational therapy faculty members obtained from a search of each academic program's website. A total of 224 responses were obtained. Descriptive statistics, ANOVAs, and Chi Square Test of Associations were used to analyze the data for the independent variables. The results showed that 60 respondents indicated that they participated in some type of faculty clinical practice as part of their faculty role. Most of this work was in a facility that was associated with the academic institution. Most of these respondents were not tenured, did not have a doctoral degree, and did not participate in administrative tasks. Most of these respondents worked in Doctoral-Extensive universities and held the Assistant Professor rank. Most worked two to four hours per week and did not receive release time or financial benefits. There were 99 respondents that indicated that they participated in moonlighting in a wide variety of settings. Most worked in their area of clinical expertise. Most of these respondents were not tenured and did not participate in administrative tasks. Only 37% had a doctoral degree. Over half had the rank of Assistant Professor. Almost 42% worked in Masters I academic institutions. Most worked less than 2 hours per week outside the faculty role and they received full financial benefits. The top three benefits for participating in clinical practice were to maintain clinical skills, enhance teaching, and improve credibility with students. The top three barriers for participating in clinical practice were teaching responsibilities, not a component in tenure decisions, and the additional responsibilities of practice. There were no statistically significant differences between the benefits or barriers to clinical practice and the Carnegie Classification of the respondent's academic institution. One ANOVA was significant between the barriers to clinical practice and if the respondent had a doctoral degree. There were no statistically significant differences between the benefits or barriers and tenure at the institution, the respondent's tenure status, the respondent's degree status, faculty rank, administrative duties, and gender except the respondents that had a doctoral degree had significantly higher barrier scores than those that did not have a doctoral degree. In general, less than five percent of the variance was explained by any of the independent variables. None of the Chi Square analyses revealed any significant differences between the academic institution's Carnegie Classification and if clinical practice was required, if a faculty participated in faculty clinical practice, or if a faculty member participated in moonlighting. In conclusion, although many faculty members recognize the benefits to participation in clinical practice, the barriers to clinical practice may be too great to outweigh the benefits for some faculty members. Most reported that clinical practice carried little weight in promotion or tenure decisions. In order for the scholarship of practice to flourish, active support from all academic institution administration is critical.

Clostridium difficile infection (CDI) prevention is of high priority. We reviewed clinical practice guidelines (CPGs), and conducted an individual participant data meta-analysis (IPMDA) of randomized controlled trials (RCTs) to assess effectiveness and safety of probiotic prophylaxis. For CPGs, we rated quality, summarized recommendations with their strength and author-reported evidence, then re-evaluated evidence. For the IPDMA, we pooled RCTs investigating probiotics versus control for CDI prevention among antibiotic consumers, using generalized linear mixed models. Our outcomes were CDI and serious adverse events (SAEs). We adjusted for age, sex, hospitalization status, and exposure to high risk antibiotics. We assessed study risk of bias and confidence in estimates of effect. Five international guidelines were evaluated, and all scored poorly for applicability, stakeholder involvement, and rigor of development. Recommendations were not always linked to evidence, and guideline authors were not transparent about how evidence limitations impacted their decisions. None of the guidelines recommended probiotics. Fourteen studies contributed data, with one pending. Probiotics reduced CDI among all studies and the adjusted model. No covariates were significantly associated with CDI. Subgroups suggested that high incidence did not affect probiotic effectiveness, and high-dose, multi-strain probiotics were more beneficial. Our estimate was robust to sensitivity analyses. Probiotics did not significantly affect SAE odds among all studies and the adjusted model. Increasing age was a significantly associated with SAEs. No SAEs were reportedly probiotics-related. For both outcomes, estimates were similar from data of obtained and not obtained studies. Confidence in estimates was moderate for both outcomes, due to low event rates. Current guidelines on CDI prevention did not adhere well to validated standards for development and reporting, most notably due to insufficient links between recommendations and supporting evidence. Our preliminary analysis suggests that probiotic prophylaxis is useful and safe for CDI prevention. / Thesis / Master of Science (MSc) / Clostridium difficile infection (CDI) is a common hospital-associated infection, and prevention is of high priority. We reviewed clinical practice guidelines on CDI prevention to summarize their recommendations, and assess the quality of guideline development and reporting. Furthermore, we analysed patient data from randomized clinical trials to obtain an overall estimate (meta-analysis) of whether using a novel strategy, probiotic prophylaxis, is effective and safe. The guidelines had several limitations, importantly that authors were not transparent about how recommendation were developed, and recommendations were not always linked to evidence. Although no guideline recommended using probiotics to prevent CDI, our advanced analysis of previously conducted trials suggested that it was an effective intervention, reducing infections by approximately 76%, and was not associated with differences in serious adverse events compared to participants not receiving probiotics. In summary, guidelines on CDI prevention should be improved, and probiotics may be considered as an additional strategy.

This dissertation presents a body of research consisting of 5 scientific papers with an overarching objective to develop and test interventions that can enhance the dissemination, access and use of current best evidence at the point of care. Questions constantly arise from clinicians’ interactions with their patients, but more than 60% remain unanswered. The first 4 papers therefore focused on evidence dissemination to clinicians and trainees looking for answers and trying to stay alert to new evidence. We used as our “laboratory” an online tool developed at McMaster University’s Health Information Research Unit, the MacPLUS Federated Search (MacPLUS FS), which allows busy clinicians to search multiple top high quality resources simultaneously and display a 1-page output with the most clinically useful results at the top. Guided by effective models for the teaching of clinical skills at the point of care, we designed 3 web-based interventions addressing logistical and educational barriers to increase the quantity and quality of searching for current best evidence. These interventions were: (A) a web-based Clinical Questions Recorder and Reminder; (B) an Evidence Retrieval Coach composed of 8 short videos embedded in MacPLUS; (C) and a Gamified Audit & Feedback based on the allocation of “badges” and “reputation scores” for evidence searching. We tested these interventions in 4 factorial randomized-controlled trials among 1,868 heath care professionals and students currently registered in MacPLUS FS, namely: 477 medical faculty members, 431 postgraduate medical trainees, 725 nursing students and 235 medical students. Results showed that these target populations substantially differed both in their baseline frequency of search and access to alerts, as in their responsiveness to the 3 web-based interventions on evidence utilization. Evidence summaries have traditionally been tailored to meet the educational needs of clinicians, but are seldom provided in a format that supports shared decision-making. Our fifth paper explored a potential solution, which constitutes another route for evidence dissemination and use. In a project called SHARE-IT, we developed a new framework and online prototype for the generic production of decision aids, which allow physicians and patients to discuss the evidence together in the clinical encounter. We present the framework, design methods and early testing of this generic approach, which showed promising results for the translation of evidence summaries into useful tools for shared decision-making. / Thesis / Doctor of Philosophy (PhD)

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms experienced when an infant has been exposed to certain substances (e.g., opioids) in-utero, resulting in health challenges for infants. Previous studies have reported substantial variations in the clinical management of NAS, suggesting that some infants may not be receiving optimal care. High-quality clinical practice guidelines are crucial to support optimal patient outcomes and standardize care. In response, I conducted a systematic review and quality appraisal of available NAS guidelines and recommendations using the AGREE-II and AGREE-REX tools. I also developed and piloted a tool to measure family-centred care in guidelines. Most guidelines received low-quality appraisal scores on the AGREE-II and the AGREE-REX appraisals (16/20 and 10/20, respectively) and have conflicting pharmacological recommendations. Findings will improve clinicians’ awareness of the variation in the quality of guidelines and assist them to make care decisions that are from the best available evidence and family-centred.

Abstract Background: Physiotherapists’ knowledge, attitude and practice patterns in falls prevention are studied mainly in middle- and high-income countries. This study aims to develop and validate a questionnaire for studying the attitude, self-reported knowledge and clinical practice of Rwandan physiotherapists in falls prevention of older adults.  Method: In a cross sectional design the content, face and cross-cultural validity was tested on four Swedish experts and four Rwandan physiotherapists. Test-retest was performed with 20 Rwandan physiotherapists and descriptive data was summarized for these physiotherapists. Content validity index (CVI) was calculated per item and scale, and face validity index with face validity index (FVI) per item and scale. Interviews complemented the face validity scorings for cross-cultural validation. Test-retest was analysed with intraclass correlation coefficient(ICC). Results were categorized into individual, behavioural and environmental factors, in line with the Social Cognitive Theory.  Results:  The questionnaire attained a satisfactory degree of content validity with content validity index per item(I-CVI) and scale-level content validity index based on the average method (S-CVI/Ave) of 0.96. Questionnaire had satisfactory face validity with a face validity index per item (I-FVI) and scale-level face validity index based on the average method (S-FVI/Ave) of 0.89. The questionnaire was shown to be pertinent to Rwandan physiotherapists’ context. The test-retest stability of the questionnaire was non-significant. Most physiotherapists emphasized individual rather than environmental or behavioral risk factors for falls and in falls prevention treatment.  Conclusion: The content and face validity as well as cross-culture validity of preliminary questionnaire of falls prevention were acceptable. Further research in this area is essential to complete validation and to improve the reliability of the questionnaire. The study highlights the importance of application of social cognitive theory in studying how physiotherapists consider the complexity of factors contributing to falls.

No description available.

BACKGROUND: Polygenic risk scores (PRS) have emerged as a promising tool for predicting the risk of developing a variety of illnesses, including psychiatric disorders. PRS are calculated by analyzing the genetic variants across the genome to assess an individual’s risk for developing a disorder. Family history (FHx) of psychiatric disorders has long been recognized as a valuable tool in assessing an individual’s risk in lieu of a genetic blood-based biomarker, like PRS. However, the accuracy of self-reported family history remains limited as a consequence of incomplete or unreliable information collected during a clinical interview. Existing risk factors for developing psychiatric disorders such as FHx tend to be non-specific in their prediction of outcome. Few research studies have evaluated the possibility of using PRS as a complement to FHx across psychosis spectrum disorders. The present study seeks to examine the relationship between the current standard indirect measure of inherited susceptibility being used, FHx, and an individual’s PRS to more directly predict risk of familial susceptibility in those diagnosed with schizophrenia (SZ) by comparing SZ probands based on their FHx of psychotic disorders diagnosis. METHODS: 396 SZ Probands with FHx data were identified. Data on polygenic risk scores for SZ (PRSSCZ) and FHx were obtained from the Bipolar-Schizophrenia Network on Intermediate Phenotypes consortium (B-SNIP 1). Genetic susceptibility was identified using PRSSCZ. FHx was established from detailed family interviews. SZ probands with only an affected first-degree relative (n= 42) or only an affected second-degree relative (n= 55) with history of a psychotic disorder diagnosis were included in the analyses. SZ probands without any affected relative (n=179) were used as a comparison group. Demographic information for all participant groups were compared using Chi-square for categorical variables, and ANOVA for continuous variables. ANCOVA was used to identify differences among relative proximity and PRSSCZ while accounting for covariates (age, sex, race). Multiple comparisons were adjusted for using Bonferroni correction. Healthy controls were added as a reference only. The significance level was set at p < 0.05. RESULTS: In SZ probands, there was a significant difference between those with an affected first-degree relative with non-affective psychosis and those without any affected relatives (p< 0.05). No significant difference was observed between those with an affected second-degree relative with non-affective psychosis and those without any affected relatives. Having only an affected first-degree relative with non-affective psychosis carries significantly more risk than having only an affected second-degree relative with non-affective psychosis (p< 0.05). CONCLUSIONS: These findings a) support the validity of taking careful family history of non-affective psychosis diagnosis when evaluating individuals with a psychotic disorder, b) suggest that PRSSCZ may be a useful complement to taking family history, and c) relative proximity is important in risk for SZ. The limitations of this study include lack of direct interviews of affected first- and second-degree relatives, and the lack of complete pedigree information that might allow for calculation of familial load.