Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.

It has been suggested that malnutrition during fetal life and early childhood may lead to increased risk of cardiovascular mortality and metabolic syndrome in adults. One way to study this has been to examine pregnancies that are a result of exposure to maternal famine and their association with subsequent development of the metabolic syndrome in adulthood. Varying findings have been demonstrated in this literature. In a famine study that examined the association between fetal famine exposure and the metabolic syndrome, no statistically significant associations were found. However, the failure to show an association could be due to the relatively short Dutch winter, limiting exposure to famine during gestation. The risk of adverse long-term consequences of famine exposure during early life may be exacerbated in later life among adults who are exposed to a nutritionally rich environment represented by a Western dietary pattern or are overweight.The aim of this study was to investigate the association between famine exposure in China during fetal life and early childhood with the risk of metabolic syndrome during adulthood and to determine whether exposure in later life to nutritional rich environments affects this association. Data were obtained from the 2002 China National Nutrition and Health Survey administered on 7874 adults born between 1954 and 1964. The risk of the metabolic syndrome was assessed among adults from 5 exposure cohorts: nonexposed, and fetal, early childhood, mid-childhood, and late childhood exposed.The severity of the famine was determined using the excess death rate in the geographical region during exposure. The metabolic syndrome defined by adenosine triphosphate (ATP) III criteria included 3 or more of the following: elevated fasting plasma triglyceride, lower plasma high-density lipoprotein (HDL) cholesterol, elevated fasting glucose levels, higher waist circumference, and hypertension.The risk of the metabolic syndrome was higher among adults born in severely affected famine areas, who had been exposed to the famine during fetal life compared with nonexposed adults (odds ratio, 3.13, 95% confidence interval, 1.24 to 7.89, P ϭ 0.016). There were similar associations among adults who were exposed to the famine during early childhood, but not among adults exposed to famine during mid or late childhood. The risk of the metabolic syndrome was especially high in later life for participants born in severely affected famine areas and had Western dietary habits or were overweight in adulthood.These findings show that exposure to famine in China during fetal life and early childhood is associated with a higher risk of metabolic syndrome in adulthood. ABSTRACTStudies examining the possible association of birth order, presentation, and mode of delivery with adverse neonatal outcomes after twin delivery have had conflicting results. The contribution of each to adverse outcomes of twin delivery is unclear.This literature review investigated whether differences in birth order, presentation, and deliv...