BACKGROUND & AIMS: OBJECTIVE:To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example. DESIGN AND SETTING:On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients' iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry. PARTICIPANTS:Patients with chronic kidney disease who were dependent on dialysis. MAIN OUTCOME MEASURES:Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines. RESULTS:There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%-32% of patients achieving haemoglobin targets of 110-120 g/L, 30%-68% achieving ferritin targets of 300-800 microg/L, and 65%-73% achieving transferrin saturation targets of 20%-50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a "proactive" (actively keeping iron levels within target range) rather than "reactive" (only reacting if iron levels are out of the range) protocol. CONCLUSIONS:Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.

背景与目标： 目的：以透析患者的铁管理为例，评估标准指南（护理患有肾功能不全的澳大利亚人[CARI]）的结果和障碍。
设计与设置：对六个澳大利亚透析单位的铁管理流程进行现场审查，这些单位的大小和位置各不相同。患者的铁指数和血红蛋白水平从澳大利亚和新西兰透析与移植注册处获得。
对象：依赖于透析的慢性肾脏病患者。
主要观察指标：储铁量和补铁指标评估过程；与CARI指南中的目标指标进行比较。
结果：各单位间达到血红蛋白和铁目标的差异很大，其中25％-32％的患者达到110-120 g / L的血红蛋白目标，30％-68％的患者达到300-800 microg /的铁蛋白目标L和65％-73％达到20％-50％的转铁蛋白饱和度目标。实施障碍包括缺乏知识，缺乏对CARI准则的认识或信任，无法实施该准则以及无法就统一的单位协议达成共识。与实现CARI指导方针目标相关的因素包括护士驱动的铁管理方案，铁管理决策辅助工具的使用，每个透析单位的肾脏病医生较少以及“主动”（将铁水平保持在目标范围内）而非“反应性”（仅在铁含量超出范围时反应）。
结论：尽管有临床实践指南，实现铁靶的可变性仍可以通过达到和维持适当铁参数的护理过程中的可变性来解释。

BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: :Recognizing the increasing commercialization and "brokerage" of organs for transplantation, the Transplantation Society has produced guidelines for organ distribution and donation of kidneys by unrelated living donors. The guidelines, reprinted here, include the stipulations that "organs should be transplanted to the most appropriate recipient on the basis of medical and immunological criteria," that sharing of organs should be arranged by national or regional networks, and that transplant surgeons should not advertise. In regard to donation by unrelated donors, the transplant team must determine that the donor's motives are altruistic; active solicitation of living unrelated donors is held to be "unacceptable," as is payment to a donor by the recipient or any supporting organization.

背景与目标： ：认识到移植器官的日益商业化和“经纪化”，移植协会制定了有关器官分布和不相关的活体捐献者捐赠肾脏的准则。该指南在此处重印，其中包括“应根据医学和免疫学标准将器官移植给最合适的接受者”的规定，器官共享应由国家或地区网络安排，并且移植医生不应做广告。关于不相关的捐赠者的捐赠，移植团队必须确定捐赠者的动机是无私的。与亲属无关的捐助者的积极征集被认为是“不可接受的”，接受者或任何支持组织对捐助者的付款也被认为是“不可接受的”。

BACKGROUND & AIMS: :Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this second of 5 sections of the guidelines of care for psoriasis, we give an overview of psoriatic arthritis including its cardinal clinical features, pathogenesis, prognosis, classification, assessment tools used to evaluate psoriatic arthritis, and the approach to treatment. Although patients with mild to moderate psoriatic arthritis may be treated with nonsteroidal anti-inflammatory drugs and/or intra-articular steroid injections, the use of disease-modifying antirheumatic drugs, particularly methotrexate, along with the biologic agents, are considered the standard of care in patients with more significant psoriatic arthritis. We will discuss the use of disease-modifying antirheumatic drugs and the biologic therapies in the treatment of patients with moderate to severe psoriatic arthritis.

背景与目标： 银屑病：牛皮癣是一种常见的，慢性，炎性，多系统疾病，主要表现为皮肤和关节表现，约占总人口的2％。在牛皮癣护理指南的5个部分的第二部分中，我们概述了牛皮癣关节炎，包括其主要临床特征，发病机理，预后，分类，用于评估牛皮癣关节炎的评估工具以及治疗方法。尽管轻度至中度银屑病性关节炎患者可以使用非甾体类抗炎药和/或关节内类固醇注射治疗，但将改变病情的抗风湿药（尤其是甲氨蝶呤）与生物制剂一起使用被认为是护理的标准在患有较严重的银屑病关节炎的患者中。我们将讨论在中重度银屑病关节炎患者中使用改变疾病的抗风湿药和生物疗法。

BACKGROUND & AIMS: OBJECTIVE:We estimated the adequacy of antibiotic therapy to guidelines for nosocomial and community-acquired urinary tract infections in hospital. DESIGN:For 4 weeks, all adult patients hospitalized with positive bacteriuria were included in our retrospective study. Data was collected from urine culture results and from patient medical files. Adequacy to guidelines was analyzed by two infectious disease specialists, focusing on the indication, antibiotic choice, dosage, route of administration, and duration of treatment. RESULTS:Overall 202 patients were enrolled in the study (63.9% women). The decision of initiating or not antibiotic therapy was appropriate in 66.8% of cases. Antibiotherapy indication and antibiotic choice were adequate in 94 cases in empiric prescription (50.8%) and in 123 cases (60.9%) after receiving culture antibiogram results. Route of administration was adequate in 94.4% and dosage in 70.8% of prescriptions. This poor compliance with guidelines was mainly due to unnecessary prescriptions in asymptomatic bacteriuria, unnecessary biotherapies and spectrum errors. CONCLUSIONS:It seems important to remind prescribers of recommendations for urinary tract infections.

背景与目标： 目的：我们根据医院和社区获得性泌尿道感染指南评估了抗生素治疗的适当性。
设计：在4周内，所有回顾性研究均纳入了所有住院且细菌尿阳性的成年患者。从尿培养结果和患者医疗档案中收集数据。两名传染病专家对指南的适用性进行了分析，重点在于适应症，抗生素选择，剂量，给药途径和治疗持续时间。
结果：本研究共纳入202名患者（63.9％为女性）。在66.8％的病例中决定是否开始抗生素治疗是适当的。接受培养物抗菌素检查结果后，经验处方的94例（50.8％）和123例（60.9％）的抗生素治疗适应症和抗生素选择均足够。给药途径在94.4％的处方中是足够的，在70.8％的处方中是剂量的。对指导原则的依从性差主要是由于无症状细菌尿的不必要处方，不必要的生物疗法和光谱错误。
结论：提醒处方者有关尿路感染的建议似乎很重要。

BACKGROUND & AIMS: :The subarachnoid hemorrhage (SAH) by aneurysmatic rupture is responsible for 6% of the cerebral vascular accidents. The cerebral aneurysms are present in 0.2-9.9% of the population and the bleeding rate is of 10 out of 100,000 inhabitants per year. The consensus conference analyzed the different schemes of treatment and made therapeutic recommendations according to the criteria of medicine based on evidence. Levels of evidence were determined from I to V. The recommendation degrees were classified in: A, determined by evidence level I, B by evidence level II, and C suggested by evidence levels III, IV and V. These recommendations should be adapted to each patient. However, grade A recommendations are treatment standards. Seriousness of patients was evaluated on the basis of Hunt and Hess scale upon admission. Successive analyses covered: general medical treatment measures, cerebral vasospasm, diagnostic procedures and treatment of the hyponatremia and convulsion prevention.

背景与目标： ：动脉瘤破裂引起的蛛网膜下腔出血（SAH）占6％的脑血管意外的原因。脑动脉瘤存在于0.2-9.9％的人口中，每年的出血量为100,000居民中的10。共识会议分析了不同的治疗方案，并根据证据依据医学标准提出了治疗建议。证据级别从I到V确定。推荐等级分为：A，由证据级别I确定，B由证据级别II确定，C由证据级别III，IV和V建议。病人。但是，A级建议是治疗标准。入院时根据Hunt和Hess量表评估患者的严重性。后续分析包括：一般医疗措施，脑血管痉挛，诊断程序以及低钠血症和抽搐预防的治疗。

BACKGROUND & AIMS: :Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.

背景与目标： 妊娠滋养细胞疾病（GTD）的子集：妊娠滋养细胞肿瘤（GTN），当肿瘤在怀孕期间通常会形成胎盘的细胞中发展时，就会发生。 《 NCCN妊娠滋养细胞赘生性疾病指南》为各种类型的GTD提供了治疗建议，包括葡萄胎，磨牙后持续GTN，低危GTN，高危GTN和中性滋养细胞肿瘤。

BACKGROUND & AIMS: :Clinical decision support systems are a combination of software techniques to help the clinicians in their medical decision making process via functionalities ranging from basic signal analysis to therapeutic planning and computerized guidelines. The algorithms providing all these functionalities must be very carefully validated on real patient data and must be confronted to everyday clinical practice. One of the main problems when developing these techniques is the difficulty to obtain high-quality complete patient records, comprising data coming both from the biomedical equipment (high-frequency signals), and from numerous other sources (therapeutics, imagery, clinical actions, etc.). In this paper, we present an infrastructure for developing and testing such software algorithms. It is based on a bedside workstation where testing different algorithms simultaneously on real-time data is possible in the ward. It is completed by a collaborative portal enabling different teams to test their software algorithms on the same patient records, making comparisons and cross-validations more easily.

背景与目标： ：临床决策支持系统是软件技术的组合，可通过从基本信号分析到治疗计划和计算机化指南等功能帮助临床医生进行医疗决策。提供所有这些功能的算法必须在真实的​​患者数据上非常仔细地验证，并且必须面对日常临床实践。开发这些技术时的主要问题之一是难以获得高质量的完整患者记录，包括来自生物医学设备（高频信号）以及来自许多其他来源（治疗，图像，临床行动等）的数据）。在本文中，我们提供了用于开发和测试此类软件算法的基础架构。它基于床头工作站，可以在病房中同时对实时数据测试不同的算法。它是由一个协作门户网站完成的，该门户网站使不同的团队可以在相同的患者记录上测试他们的软件算法，从而使比较和交叉验证更加容易。

BACKGROUND & AIMS: : Background: The incidence of micropapillary thyroid carcinoma (mPTC) has increased in the last decade. Active surveillance (AS) has been proposed as an alternative management for low-risk mPTC based on preoperative Kuma criteria. Controversy still exists on how to appropriately manage this group of patients, as some low-risk mPTC may harbor some postoperative features associated with disease recurrence as described in the 2015 American Thyroid Association (ATA) guidelines. Methods: We retrospectively reviewed 108 patients with histopathologic diagnosis of mPTC after surgery at a third level hospital in Mexico City from 2000 to 2018. Demographic and clinicopathologic data were analyzed as predictors for disease recurrence and/or metastatic disease (lymph node or distant). Comparison between group stratification based on preoperative Kuma criteria and postoperative 2015 ATA guidelines risk criteria for disease recurrence was performed. Measures of diagnostic accuracy were obtained for preoperative risk features according to the Kuma criteria. Results: Of 108 patients, 79 (73%) were classified as preoperative high-risk mPTC and 29 (27%) as low risk based on the Kuma criteria. Of these 79 high-risk patients, 38 (48%) were reclassified as low risk for disease recurrence, 12 (15%) as intermediate risk, and 29 (37%) remained as high risk based on the 2015 ATA risk criteria. Of the 29 preoperative low-risk patients, 19 (65.5%) remained as postoperative low risk for disease recurrence, 2 (7%) as intermediate risk, and 8 (27.5%) as high risk. Higher accuracy of preoperative risk features was obtained for lymph node and distant metastases, 84.2% and 97.2%, respectively. After multivariate analysis, age <40 years and microscopic extrathyroidal extension (ETE) were associated with higher risk for metastatic disease (lymph node or distant) in our cohort. Conclusions: Patients with mPTC under 40 years old and microscopic ETE are more prone to develop metastatic disease (lymph node or distant). One-third of our patients stratified as low-risk mPTC according to the Kuma criteria for AS had histopathologic features associated with a more aggressive clinical behavior or structural recurrence. In addition, lymph node and distant metastases are the preoperative risk features with the highest diagnostic accuracy for preoperative risk stratification.

背景与目标： ：
背景：
在最近十年中，微乳头状甲状腺癌（mPTC）的发病率有所增加。已提出基于术前Kuma标准的主动监视（AS）作为低风险mPTC的替代管理方法。关于如何适当地治疗该组患者仍存在争议，因为某些低风险的mPTC可能具有2015年美国甲状腺协会（ATA）指南中所述的与疾病复发相关的一些术后特征。
方法：
我们回顾性分析了2000年至2018年在墨西哥城三级医院接受手术治疗的108例mPTC的组织病理学诊断。分析了人口统计学和临床​​病理学数据，作为疾病复发和/或转移性疾病（淋巴结或远处）的预测指标。根据术前Kuma标准和术后2015 ATA指南疾病复发风险标准对组分层进行了比较。根据Kuma标准获得了术前风险特征的诊断准确性测量。
结果：
根据库玛标准，在108例患者中，有79例（73％）被归为术前高危mPTC，29例（27％）被归为低危。根据2015年ATA风险标准，在这79例高危患者中，有38例（48％）被重新分类为低疾病复发风险，12例（15％）被分类为中度风险，29例（37％）仍然被分类为高风险。在29例术前低危患者中，有19例（65.5％）仍为术后疾病复发的低风险，2例（7％）为中度风险，8例（27.5％）为高风险。淋巴结和远处转移的术前风险特征的准确性更高，分别为84.2％和97.2％。经过多变量分析，年龄<40岁和镜下甲状腺外扩展（ETE）与我们队列中转移性疾病（淋巴结或远处）的较高风险相关。
结论：
40岁以下的mPTC和镜下ETE的患者更容易发生转移性疾病（淋巴结或远处）。根据Kuma AS的标准，我们三分之一的患者被归为低危mPTC，其组织病理学特征与更积极的临床行为或结构复发相关。此外，淋巴结转移和远处转移是术前危险分层，对术前危险分层的诊断准确性最高。

BACKGROUND & AIMS: PURPOSE:To identify barriers to implementation of an evidence based integrated care pathway (ICP) for seizure management in the Emergency Department (ED). METHODS:A site specific bespoke questionnaire was designed to solicit anonymous responses from all grades of ED medical and nursing staff to a series of questions regarding utility, feasibility, significance and implementation of a locally designed and championed ICP for seizure management and onward referral. RESULTS:While 95% of respondents agreed that the pathway ensured patients were treated according to best practice, a number of human factors were identified as barriers to use. These fell into three categories 1) environmental 2) pathway design/process and 3) user related issues. CONCLUSIONS:Most respondents understood and endorsed the evidence based utility of the pathway. Barriers to use, however, are broad with interactions involving many complex human factors. Nevertheless, solutions can be relatively easily formulated but departmental-wide effort is required to comprehensively address all issues.

背景与目标： 目的：为急诊科（ED）的癫痫发作管理确定基于证据的综合护理途径（ICP）的障碍。
方法：设计了针对特定地点的定制问卷，以征求各级别ED医务和护理人员的匿名答复，涉及一系列有关癫痫发作管理和转诊的本地设计和拥护ICP的实用性，可行性，重要性和实施问题。
结果：尽管95％的受访者同意该途径可确保按照最佳实践对患者进行治疗，但许多人为因素被确定为使用障碍。这些问题分为三类：1）环境2）途径设计/过程以及3）与用户相关的问题。
结论：大多数受访者理解并认可该途径的循证实用性。但是，由于涉及许多复杂的人为因素的相互作用，使用的障碍是广泛的。然而，解决方案可以相对容易地制定，但是需要部门范围内的努力来全面解决所有问题。

BACKGROUND & AIMS: BACKGROUND:National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology-based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention. OBJECTIVE:We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment. METHODS:Multislice computed tomography was performed in 114 consecutive patients (mean age 57+/-14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low-, intermediate-, and high-risk) according to their Framingham risk scores (FRS). RESULTS:Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n=12/114) of the patients met high-risk criteria requiring aggressive cholesterol reduction. Of those in the low- and intermediate-risk groups, MSCT found coronary plaque in 76% (n=77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high-risk category. Use of statin drugs increased from 32% at baseline to 53% (p=0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low-density lipoprotein cholesterol (LDL-c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p<0.001). CONCLUSION:Multislice computed tomography reclassifies a high percentage of patients considered to be low- to intermediate-risk into the high-risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid-lowering therapy.

背景与目标： 背景：国家胆固醇教育计划（NCEP）指南已用于定义高胆固醇血症患者的治疗目标。但是，基于流行病学的指南无法识别出患有冠状动脉疾病的所有受试者进行积极的脂质干预。
目的：我们试图评估多层计算机断层扫描（MSCT）血管造影对脂质治疗的NCEP指南分类的附加价值。
方法：对114例无已知冠状动脉疾病的连续患者（平均年龄57 / -14岁；男性59％）进行了多层计算机断层扫描。根据弗雷明汉风险评分（FRS）将受试者分为3类（低，中和高风险）。
结果：传统的心脏危险因素是常见的：高血压59％，糖尿病13％，吸烟22％。根据FRS，11％（n = 12/114）的患者符合需要积极降低胆固醇的高风险标准。在低危和中危组中，MSCT发现冠状动脉斑块占76％（n = 77/102），中度或重度斑块占38％（n = 39/102），因此将其重新分类为高危风险类别。根据MSCT结果，他汀类药物的使用从基线的32％增加到53％（p = 0.002）；在已经接受他汀类药物治疗的患者中，有31％的患者增加了他汀类药物的剂量。 MSCT后，平均低密度脂蛋白胆固醇（LDL-c）从114 mg / dL降至91 mg / dL（p <0.001）。
结论：多层计算机断层扫描根据其冠状动脉病变将高百分比的被认为是低风险至中风险的患者重新分类为高风险类别。因此，目前MSCT使用量的增加可能对降脂治疗中临床医生的实践模式产生重大影响。

BACKGROUND & AIMS: :Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

背景与目标： ：非曲张性胃肠道出血（GIB）是全球范围内死亡率和发病率的重要原因，在门诊和医院环境中都遇到这种情况。胃肠道（GI）出血分为上GIB，小肠出血（以前也称为模糊GIB）或下GIB。尽管GIB的病因是多种多样的，但使用非甾体类抗炎药是一个强大而持续的危险因素。内镜下GIB的诊断和治疗取得了进步，从而改善了结局。我们介绍了有关非静脉GIB的诊断和管理的当前实践的最新回顾，以及可能的未来方向。

BACKGROUND & AIMS: BACKGROUND:Autoimmune encephalitis is characterized by neuropsychiatric symptoms associated with brain inflammation. The differential is usually broad and Psychiatry often collaborates with Neurology in diagnostic clarification and symptom management. At least 40% of neuroencephalitis cases are of unknown etiology which adds to difficulties in making the right diagnosis and deciding on the appropriate treatment (Granerod et al., Lancet Infect Dis 10:835-44, 2010). The aim of this case series was to present four cases with complicated psychiatric symptomatology and isolated neurologic signs and symptoms, evaluated at a large tertiary medical center and treated for suspected autoimmune encephalitis, demonstrating the complexity of diagnosis and treatment. CASE PRESENTATION:Four diagnostically challenging and heterogeneous cases displayed clinical symptomatology suggestive of autoimmune encephalitis. All cases presented with neurologic and psychiatric symptoms, but had negative autoantibody panels, normal or inconclusive magnetic resonance imaging results and non-specific cerebrospinal fluid changes. All were challenged with immunosuppressive/immunomodulatory treatments with overall poor response rates. CONCLUSIONS:There is a heterogeneous presentation of autoimmune encephalitis in pediatric populations. In the absence of positive findings on testing, individuals who do not meet proposed criteria for seronegative encephalitis may be misdiagnosed, and/or may not respond adequately to treatment. In those cases, comprehensive evaluation and stringent application of consensus guidelines is necessary.

背景与目标： 背景：自身免疫性脑炎的特征是与脑部炎症相关的神经精神症状。差异通常很大，精神病学经常与神经病学合作进行诊断澄清和症状管理。至少40％的神经脑炎病例病因不明，这在做出正确的诊断和确定适当的治疗方法时增加了困难（Granerod等，Lancet Infect Dis 10：835-44，2010）。本病例系列的目的是介绍四例具有复杂精神症状和孤立的神经系统症状和症状的病例，这些病例在大型三级医疗中心进行了评估，并进行了疑似自身免疫性脑炎的治疗，证明了诊断和治疗的复杂性。
病例介绍：4例具有诊断挑战性和异类病例显示出临床症状，提示自身免疫性脑炎。所有病例均表现出神经和精神症状，但自身抗体阴性，磁共振成像结果正常或无定论，脑脊液无特异性改变。所有患者均受到免疫抑制/免疫调节治疗的挑战，总体反应率较差。
结论：小儿人群自身免疫性脑炎存在异质性表现。在缺乏阳性检测结果的情况下，不符合血清阴性脑炎提议标准的患者可能会被误诊和/或对治疗没有足够的反应。在这种情况下，有必要对共识准则进行全面评估和严格应用。

BACKGROUND & AIMS: :There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

背景与目标： ：世界范围内的阴道手术分娩率（OVD）范围很广，这反映了各种本地实践模式，训练有素的临床医生人数以及缺乏国际循证指南。这项研究的目的是审查和比较已发表的OVD指南中的建议。因此，对皇家妇产科学院（RCOG），澳大利亚皇家新西兰妇产科学院（RANZCOG），加拿大妇产科医师学会（SOGC）和美国妇产科医师（ACOG）进行了阴道阴道分娩。所有指南均指出，任何仪器的使用均应基于临床情况和操作人员的经验。在所审查的指南中，OVD的适应症，禁忌症，前提条件和分类总体上非常相似。此外，他们都同意不应常规进行会阴切开术。 RCOG，RANZCOG和SOGC描述了一些可促进自发性阴道分娩并因此减少对OVD需求的干预措施。他们还强调了适当的产后护理和咨询的重要性。对于应使用的实际技术尚未达成共识，包括镊子或真空杯的类型，牵引力和持续时间或允许的脱离次数。因此，需要国际惯例协议，以鼓励临床医生在指示时使用OVD，最大程度地减少并发症并降低剖宫产率。