Factors affecting the outcome of temporary sacral nerve stimulation for faecal incontinence. The value of the new tined lead electrode

Baseline Anal Sphincter Elastance May Predict Long-Term Outcomes of Sacral Neuromodulation for Fecal Incontinence

INTRODUCTION

Anal acoustic reflectometry (AAR), a novel test of anal sphincter function, was shown to predict a successful trial phase of sacral neuromodulation (SNM) for fecal incontinence. This follow-up study aims to explore if AAR can also predict short- and long-term SNM outcomes at less than and more than 5 y, respectively.

METHODS

Outcome data were reviewed from a prospectively managed database. Successful treatment was defined as >50% improvement in patient reported fecal incontinence or urgency episodes, or in a symptom severity score.

RESULTS

Twenty-six female patients (median: 53 y [range 31-80]) who received a permanent SNM implant were analyzed. In the short-term, no differences were observed in baseline AAR and symptom severity parameters between patients reporting success or failure. At long-term follow-up (median: 122 mo [113-138]) data was available from 17 (17/26, 65%) patients with 7 (7/17, 41%) reporting continued treatment success. Baseline fecal urgency episodes (P = 0.003), and the AAR parameters of opening elastance (P = 0.043) and squeeze opening elastance (P = 0.025) were significantly different between patients reporting success and those reporting failure. Squeeze opening elastance demonstrated the greatest ability to discriminate between success and failure (area under the curve: 0.82 (95% confidence interval 0.60-1.01, P = 0.003)).

CONCLUSIONS

AAR may have a role in identifying patients suitable for SNM treatment with clinically relevant metrics associated with successful response to treatment. Future work should explore this further to improve SNM patient selection.

The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single-Center Experience

BACKGROUND

Sacral neuromodulation is an effective treatment for fecal incontinence.

OBJECTIVE

To assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices.

DESIGN

This is an observational study of patients treated for >5 years. A positive outcome was defined as a more than 50% reduction in fecal incontinence episodes or improvement in a symptom severity score. Data were reviewed from a prospectively managed database.

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

Data from 74 patients (72 women) were available at long-term follow-up.

MAIN OUTCOME MEASURES

Bowel diary, St. Mark's incontinence score, and Manchester Health Questionnaire data were prospectively recorded at baseline, after percutaneous nerve evaluation, and at last follow-up.

RESULTS

Patients were analyzed in cohorts based on time since sacral neuromodulation implantation: group 1: 5 to 10 years (n = 20), group 2: >10 years (n = 35), and group 3: inactive sacral neuromodulation devices (n = 19). Median St. Mark's incontinence score and Manchester Health Questionnaire improved from baseline to last follow-up in group 1 ( p ≤ 0.05) and group 2 ( p ≤ 0.05), but in group 3, results returned to baseline levels at the last follow-up. Similarly, weekly fecal incontinence episodes improved in both active device groups at the last follow-up. However, in group 3, incontinence episodes were no different from baseline ( p = 0.722). Despite active devices, fecal urgency episodes increased at the last follow-up after >10 years since percutaneous nerve evaluation ( p ≤ 0.05). Complete continence was reported by 44% of patients, and at least a 50% improvement was seen in 77% of patients with active devices.

LIMITATIONS

This study is retrospective with some gaps in the available data at the last follow-up.

CONCLUSIONS

Sacral neuromodulation is an effective treatment for fecal incontinence in the long term, but all outcomes are adversely affected by device inactivity. Therefore, ongoing stimulation is required for continued benefit. See Video Abstract.

RESULTADOS A LARGO PLAZO DE LA NEUROMODULACIN SACRA PARA LA INCONTINENCIA FECAL EXPERIENCIA DE UN SOLO CENTRO

ANTECEDENTES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados a largo plazo de la neuromodulación sacra y establecer los resultados de los pacientes con dispositivos inactivos.DISEÑO:Este es un estudio observacional de pacientes tratados durante más de 5 años. Un resultado positivo se definió como una reducción >50 % en los episodios de incontinencia fecal o una mejoría en la puntuación de gravedad de los síntomas. Los datos se revisaron a partir de una base de datos administrada prospectivamente.ENTERNO CLINICO:Este estudio se realizó en un solo centro de referencia terciario.PACIENTES:Los datos de 74 pacientes (72 mujeres) estaban disponibles en el seguimiento a largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:Diario intestinal, puntuación de incontinencia de St. Mark y datos del Cuestionario de salud de Manchester se registraron prospectivamente al inicio, después de la evaluación de nervio periférico y en el último seguimiento.RESULTADOS:Los pacientes se analizaron en cohortes según el tiempo transcurrido desde la implantación de la neuromodulación sacra: Grupo 1: 5-10 años (n = 20), Grupo 2: >10 años (n = 35) y Grupo 3: dispositivos SNM inactivos (n = 19). La mediana de la puntuación de incontinencia de St. Mark y Questionnaire Cuestionario de salud de Manchester mejoraron desde el inicio hasta el último seguimiento en el Grupo 1 (p = < 0,05) y el Grupo 2 (p = < 0,05), pero en el Grupo 3 los resultados volvieron a los niveles iniciales en el último seguimiento. arriba. De manera similar, los episodios semanales de incontinencia fecal mejoraron en ambos grupos de dispositivos activos en el último seguimiento. Sin embargo, en el Grupo 3 los episodios de incontinencia no fueron diferentes de los basales (p = 0,722). A pesar de los dispositivos activos, los episodios de urgencia fecal aumentaron en el último seguimiento después de más de 10 años desde la evaluación del nervio periférico (p = < 0,05). Continencia completa se reportó en el 44 % de los pacientes, y al menos una mejora del 50 % en el 77 % con dispositivos activos.LIMITACIONES:Este estudio es retrospectivo con algunas vacíos en los datos disponibles en el último seguimiento.CONCLUSIONES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal a largo plazo, pero todos los resultados se ven afectados negativamente por la inactividad del dispositivo. Por lo tanto, se requiere estimulación continua para un beneficio continuo. (Traducción- Dr. Francisco M. Abarca-Rendon ).

[Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management]

BACKGROUND

Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence.

METHODS AND RESULTS

A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable.

CONCLUSION

Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.

Current and future perspectives on the utility of provocative tests of anal sphincter function: A state-of-the-art summary

BACKGROUND

The maintenance of fecal continence depends upon coordinated interactions between the pelvic floor, anorectum, and anal sphincter complex orchestrated by central and peripheral neural activities. The current techniques to objectively measure anorectal function rely on fixed diameter catheters placed inside the anal canal with a rectal balloon to obtain measurements of anal resting and squeeze function, and rectal compliance. Until recently it had not been possible to measure the distensibility of the anal canal, or in other words its ability to resist opening against an increasing pressure, which has been proposed as the main determinant of a biological sphincter's function. Anal acoustic reflectometry (AAR) and the functional lumen imaging probe (FLIP) are two novel, provocative techniques that dynamically assess the anal sphincter complex under volume-controlled distension. In doing so, both provide information on the viscoelastic properties of the anal canal and offer new insights into its function.

PURPOSE

This review details the current and potential future applications of AAR and FLIP and highlights the unanswered questions relevant to these new technologies.

Using Augmented Reality for Intraoperative Guidance During Sacral Neuromodulation System Implantation

Objective

The purpose of this study was to examine the feasibility of using augmented reality during lead placement for sacral nerve stimulation (SNS).

Methods

The study was a prospective case series performed in a single tertiary center. Patients with fecal incontinence or urinary retention eligible for SNS according to the American society of colon and rectal surgeon's guidelines were included. Each patient underwent a computerized tomography scan of the sacrum and pelvic floor before surgery; and a segmentation of the sacral bone, the skin, and three fiducial markers on the lower back was produced. Surgical planning included the design of an ideal virtual transmission tract leading to the S3 foramen using the most suitable location and needle trajectory for introducing the lead. During the surgical intervention, a needle was inserted into the S3 foramen using the aligned tract as visualized using the Microsoft HoloLens first generation head mounted unit.

Results

Overall, 11 patients were included. Mean operative time was 43.8 minutes (range 25-81 minutes). All patients reported a significant reduction from the preoperative level of the mean postoperative Cleveland Clinic Incontinence Score (CCIS) assessed 2 weeks after the temporary SNS implant (CCIS preoperative 13.3, postoperative 8.5; CI -7.35 to -2.25; P < 0.01). The surgeons reported the imaging useful, allowing accurate and easier approach.

Conclusions

Intraoperative augmented reality imaging for needle application during SNS appears to be feasible, practical, and may be useful in additional procedures.

Sacral Nerve Stimulation for Fecal Incontinence: How Long Should the Test Phase Be?

BACKGROUND

Decision-making for pulse generator implantation for sacral nerve stimulation in the management of fecal incontinence is based on the results of a test phase. Its duration is still a matter of debate.

OBJECTIVE

The purpose of this study was to determine whether an early positive response during the test phase could predict implantation of a permanent sacral nerve pulse generator.

DESIGN

This was a short-term observational cohort study. A positive response was defined as a >50% decrease of fecal leaks compared with baseline. A multivariate logistic regression was computed to predict pulse generator implantation after the first week of the test phase.

SETTINGS

The study was conducted in 3 national referral centers.

PATIENTS

From January 2006 to December 2012, 144 patients with fecal incontinence enrolled in a prospectively maintained database completed a 2- to 3-week bowel diary, at baseline and during test phase.

MAIN OUTCOME MEASURES

The primary outcome was the clinical decision to implant a pulse generator. The primary predictor was a calculated score including the number of leak episodes, bowel movements, and urgencies and the time to defer defecation expressed in minutes during the first screening test week.

RESULTS

After the first, second and third week of the test phase, 81 (56%) of 144, 96 (67%) of 144, and 93 (70%) of 131 patients had a positive test. A permanent pulse generator was implanted in 114. Time to defer defecation increased during the 3 weeks of screening. Urgencies were unchanged. The computed score was predictive of a permanent pulse generator implantation (Se = 72.6% (95% CI, 59.8-83.1); Sp = 100% (95% CI, 78.2-100); c-index = 0.86 (95% CI, 0.78-0.94)).

LIMITATIONS

No cost analysis or projection based on our proposal to reduce the test phase has been made.

CONCLUSIONS

Permanent pulse generator implantation can be safely proposed early (1-week screening) to fast responders. Nonetheless, permanent implantation may be decided as well in patients exhibiting a delayed response. Whether a rapid response to sacral nerve stimulation could be predictive of a long-term response remains to be determined. See Video Abstract at http://links.lww.com/DCR/A452.

Sacral nerve stimulation--hidden costs (uncovered)

AIM

The aim of this study is to determine the occurrence of surgical revision in a cohort of patients treated with sacral nerve stimulation (SNS) for faecal incontinence and constipation and to establish the types of procedures performed and indications for surgery.

METHOD

From the years 2002 to 2014, 125 patients were identified who had undergone permanent SNS therapy with 36 (28.8 %) patients requiring surgical intervention postimplantation. These cases were retrospectively reviewed (range of follow-up 1-99 months).

RESULTS

Over a total of 1512 months of SNS treatment, 51 unplanned surgical procedures were required in 36 patients. At present, 48 procedures have been performed at an average of 2.6 years following implantation and three patients are awaiting surgery. Lead-related problems accounted for 30 (58.8 %) procedures at an average of 1.7 years affecting 22 patients. Battery and implantable pulse generator-related problems attributed to 13 procedures (25.5 %) in 12 patients at an average of 5.0 years. Battery depletion occurred in seven patients at an average of 5.4 years. Surgical revision was required to replace, remove, or resite various components of the SNS system. Indications for surgery included lead damage, pain and loss or lack of SNS efficacy. Explantation was warranted in six patients due to poor SNS efficacy, pain, infection and facilitation of a magnetic resonance imaging scan. This was performed at an average of 1.6 years.

CONCLUSION

A considerable proportion of patients treated with SNS therapy require surgical revision. These unplanned procedures are associated with substantial unexpected costs that financially burden SNS services.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Sacral nerve stimulation for faecal incontinence and constipation: a European consensus statement

AIM

In Europe during the last decade sacral nerve stimulation (SNS) or sacral neuromodulation (SNM) has been used to treat faecal incontinence (FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/SNM for FI and constipation.

METHOD

A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion.

RESULTS

Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%).

CONCLUSION

Consensus was achieved on the majority of domains of SNS/SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/SNM in Europe.

The technique of sacral nerve modulation

AIM

The aim of this review was to summarize current knowledge and recommendations regarding the technique of implantation of the electrode in performing sacroneuromodulation (SNM) and the available information on programming parameters and implantation algorithms.

METHOD

All English-language articles published from January 1985 to December 2013 that reported the SNM surgical technique and results were considered for inclusion. Data were considered useful for the present review only if related to: (i) peripheral nerve evaluation; (ii) temporary nerve stimulation; (iii) definitive impulse generator placement; and (iv) parameters programming.

RESULTS

The literature search revealed 193 potentially relevant studies from initial electronic search terms and eligibility criteria, and these studies were evaluated in detail. In total, 41 studies were included in the final analysis. Of the studies reviewed, the majority (n = 37) were prospective or retrospective case series. Only three randomized clinical trials were eligible for inclusion.

CONCLUSION

Although the technique seems to be standardized, several steps still need to be clarified in order to define the best way to perform the procedure and then to maximize the outcome.

Long-term outcomes of sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) has proven short- to medium-term effectiveness for the treatment of faecal incontinence (FI); fewer long-term outcomes have been presented and usually in small series. Here, the long-term effectiveness of SNS was evaluated in a large European cohort of patients with a minimum of 5 years' follow-up.

METHODS

Prospectively registered data from patients with FI who had received SNS for at least 5 years from ten European centres were collated by survey. Daily stool diaries, and Cleveland Clinic and St Mark's incontinence scores were evaluated at baseline, after implantation and at the last follow-up. SNS was considered successful when at least 50 per cent symptom improvement was maintained at last follow-up.

RESULTS

A total of 407 patients underwent temporary stimulation, of whom 272 (66·8 per cent) had an impulse generator implanted; 228 (56·0 per cent) were available for long-term follow-up at a median of 84 (i.q.r. 70-113) months. Significant reductions in the number of FI episodes per week (from median 7 to 0·25) and summative symptom scores (median Cleveland Clinic score from 16 to 7, St Mark's score from 19 to 6) were recorded after implantation (all P < 0·001) and maintained in long-term follow-up. In per-protocol analysis, long-term success was maintained in 71·3 per cent of patients and full continence was achieved in 50·0 per cent; respective values based on intention-to-treat analysis were 47·7 and 33·4 per cent. Predictive analyses determined no significant association between pretreatment variables and successful outcomes. Risk of long-term failure correlated with minor symptom score improvement during the temporary test phase.

CONCLUSION

SNS remains an effective treatment for FI in the long term for approximately half of the patients starting therapy.

Sacral neuromodulation for bowel dysfunction: a consensus statement from the Italian group

BACKGROUND

Representatives from the Italian centers experienced in sacral neuromodulation (SNM) for the treatment of bowel dysfunction met in order to define the current clinical practice in Italy and to produce a consensus statement regarding indications for this therapy and patient management.

METHODS

Fifty Italian colonproctologists were asked to complete a questionnaire concerning their clinical practice in SNM (290 questions, grouped within 4 broad areas). Physicians expressed their opinion by completing the questionnaire, assigning to each statement their level of agreement according to the 5-point Likert scale; the data were analyzed by attributing to each expert's answers a weight proportional to the degree of experience. During a meeting held 2 months later, the critical aspects of the therapy were re-examined and discussions held with the goal of reaching an agreement on controversial topics. The available literature was reviewed.

RESULTS

Patient selection criteria, etiology, diagnostic investigations, test procedures and implantation, follow-up and evaluation of results have been reviewed. The aim was to achieve an algorithm for patient management, showing the place of SNM in the treatment of bowel dysfunction. The approach in case of treatment failure was also discussed.

CONCLUSIONS

Analysis of the data collected reveals substantial consensus at the national level concerning all the main points with regard to the therapy. The recommendations expressed in this article can be considered as national guidelines and taken into account by the principal international implantation centers.

The effects of sacral nerve stimulation on continence are temporarily maintained after turning the stimulator off

AIM

Sacral nerve stimulation is an effective treatment for urinary and faecal incontinence even though its mechanism of action is uncertain. Central nervous system involvement by 'setting-up' neurological mechanisms appointed to control pelvic function has been hypothesized. The study aimed to evaluate whether the effects of long-term sacral nerve stimulation are memorized and therefore maintained after switching off the stimulator.

METHOD

Patients having sacral nerve stimulation for faecal and/or urinary incontinence for at least 1 year had the stimulator turned off and the results monitored. Data recorded with the stimulator off were compared with post-implant data. If symptoms recurred the stimulator was switched back on. Nineteen patients entered the study. Fourteen had faecal and/or urinary incontinence and five had faecal incontinence alone. The symptoms were assessed by means of a bowel function diary and dedicated questionnaire.

RESULTS

In 10 patients symptoms recurred at different intervals after a median off period of 3.4 months with a probability of symptom relapse of 55%. The Fecal Incontinence Quality of Life (FIQL) score did not show any significant difference in nine patients with the stimulator off for at least 1 year. No factors predictive of symptom recurrence were identified although an idiopathic aetiology, severity of disease and urinary incontinence had higher hazard ratios. During the off period, none of the scores and episodes of incontinence showed significant changes compared with the on period.

CONCLUSION

The effects of sacral nerve stimulation on faecal and urinary incontinence were maintained in about half of patients after switching the stimulator off, but in some symptoms returned after different periods of time. The data shed new light on possible effects of sacral nerve stimulation on brain neuroplasticity in the control of continence.

Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients

AIM

Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined.

METHOD

Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI.

RESULTS

Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC-curve was 0.84 (P < 0.001; 95% confidence interval, 0.80-0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure.

CONCLUSION

Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.

Postoperative issues of sacral nerve stimulation for fecal incontinence and constipation: a systematic literature review and treatment guideline

BACKGROUND

There is a lack of knowledge on the incidence and management of suboptimal therapeutic effect and the complications associated with sacral nerve stimulation for fecal incontinence and constipation.

OBJECTIVE

This study aimed to review current literature on postoperative issues and to propose a treatment algorithm.

DATA SOURCE

PubMed, MEDLINE, and EMBASE were searched using the keywords "sacral nerve stimulation," "sacral neuromodulation," "fecal incontinence," and "constipation" for English-language articles published from January 1980 to August 2010. A further search was conducted on a wider literature using the keywords "complication," "adverse effect," "treatment failure," "equipment failure," "infection," "foreign-body migration," "reoperation," "pain," and "algorithm."

STUDY SELECTION

Four hundred sixty-one titles were identified, and after a title and abstract review, 135 were subjected to full article review; 89 were finally included in this review. Five articles were added by manual search and consensus.

RESULTS

Forty-eight studies were identified as cohort studies reporting on postoperative issues, including 1661 patients who underwent percutaneous nerve evaluation and 1600 patients who proceeded to sacral nerve stimulation therapy. Pooled data showed that the most common problem during percutaneous nerve evaluation was lead displacement (5.3%). The incidence of suboptimal outcome, pain, and infection after implantation was 12.1%, 13.0%, and 3.9%.

LIMITATIONS

There was significant underreporting of untoward events, because 60% of the studies did not report complications during percutaneous nerve evaluation, and suboptimal outcome after implantation was not disclosed in 44% of the studies.

CONCLUSIONS

The incidence of untoward events associated with sacral nerve stimulation appears to be low. However, there is a significant underreporting of the incidence. Using the information from the structured and systematic literature review, we formulated a clinically relevant guideline for reporting and managing postoperative issues. The guideline can provide a framework for clinical practice.