Application of GRADE: making evidence-based recommendations about diagnostic tests in clinical practice guidelines

Diagnostic utility of FDG-PET in the differential diagnosis between different forms of primary progressive aphasia

Purpose

A joint effort of the European Association of Nuclear Medicine (EANM) and the European Academy of Neurology (EAN) aims at clinical guidance for the use of FDG-PET in neurodegenerative diseases. This paper addresses the diagnostic utility of FDG-PET over clinical/neuropsychological assessment in the differentiation of the three forms of primary progressive aphasia (PPA).

Methods

Seven panelists were appointed by the EANM and EAN and a literature search was performed by using harmonized PICO (Population, Intervention, Comparison, Outcome) question keywords. The studies were screened for eligibility, and data extracted to assess their methodological quality. Critical outcomes were accuracy indices in differentiating different PPA clinical forms. Subsequently Delphi rounds were held with the extracted data and quality assessment to reach a consensus based on both literature and expert opinion.

Results

Critical outcomes for this PICO were available in four of the examined papers. The level of formal evidence supporting clinical utility of FDG-PET in differentiating among PPA variants was considered as poor. However, the consensual recommendation was defined on Delphi round I, with six out of seven panelists supporting clinical use.

Conclusions

Quantitative evidence demonstrating utility or lack thereof is still missing. Panelists decided consistently to provide interim support for clinical use based on the fact that a typical atrophy or metabolic pattern is needed for PPA according to the diagnostic criteria, and the synaptic failure detected by FDG-PET is an earlier phenomenon than atrophy. Also, a normal FDG-PET points to a non-neurodegenerative cause.

[GRADE Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical practice and public health]

OBJECTIVE

To describe the Grading of Recommendations Assessment, Development and Evaluation (GRADE) interactive Evidence to Decision (EtD) frameworks for tests and test strategies for clinical, public health or coverage decisions.

STUDY DESIGN AND SETTING

As part of the GRADE Working Group's DECIDE project we conducted workshops, user testing with systematic review authors, guideline developers and other decision makers, and piloted versions of the EtD framework.

RESULTS

EtD frameworks for tests share the structure, explicitness, and transparency of other EtD frameworks. They require specifying the purpose of the test, linked or related management and the key outcomes of concern for different test results and subsequent management. The EtD criteria address test accuracy and assessments of the certainty of the additional evidence necessary for decision-making. When there is no direct evidence of test effects on patient important outcomes, formal or informal modeling is needed to estimate effects. We describe the EtD criteria based on examples developed with GRADEpro (www.gradepro.org), GRADE's software that also provides interactive Summary of Findings Tables.

CONCLUSION

EtD frameworks for developing recommendations and making decisions about tests lay out the sequential steps in reviewing and assessing the different types of evidence that need to be linked.

Accuracy of Nasal Nitric Oxide Measurement as a Diagnostic Test for Primary Ciliary Dyskinesia. A Systematic Review and Meta-analysis

RATIONALE

Primary ciliary dyskinesia (PCD) is a rare disorder causing chronic otosinopulmonary disease, generally diagnosed through evaluation of respiratory ciliary ultrastructure and/or genetic testing. Nasal nitric oxide (nNO) measurement is used as a PCD screening test because patients with PCD have low nNO levels, but its value as a diagnostic test remains unknown.

OBJECTIVES

To perform a systematic review to assess the utility of nNO measurement (index test) as a diagnostic tool compared with the reference standard of electron microscopy (EM) evaluation of ciliary defects and/or detection of biallelic mutations in PCD genes.

DATA SOURCES

Ten databases were searched for reference sources from database inception through July 29, 2016.

DATA EXTRACTION

Study inclusion was limited to publications with rigorous nNO index testing, reference standard diagnostic testing with EM and/or genetics, and calculable diagnostic accuracy information for cooperative patients (generally >5 yr old) with high suspicion of PCD.

SYNTHESIS

Meta-analysis provided a summary estimate for sensitivity and specificity and a hierarchical summary receiver operating characteristic curve. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess study quality, and Grading of Recommendations Assessment, Development, and Evaluation was used to assess the certainty of evidence. In 12 study populations (1,344 patients comprising 514 with PCD and 830 without PCD), using a reference standard of EM alone or EM and/or genetic testing, summary sensitivity was 97.6% (92.7-99.2) and specificity was 96.0% (87.9-98.7), with a positive likelihood ratio of 24.3 (7.6-76.9), a negative likelihood ratio of 0.03 (0.01-0.08), and a diagnostic odds ratio of 956.8 (141.2-6481.5) for nNO measurements. After studies using EM alone as the reference standard were excluded, the seven studies using an extended reference standard of EM and/or genetic testing showed a summary sensitivity of nNO measurements of 96.3% (88.7-98.9) and specificity of 96.4% (85.1-99.2), with a positive likelihood ratio of 26.5 (5.9-119.1), a negative likelihood ratio of 0.04 (0.01-0.12), and a diagnostic odds ratio of 699.3 (67.4-7256.0). Certainty of the evidence was graded as moderate.

CONCLUSIONS

nNO is a sensitive and specific test for PCD in cooperative patients (generally >5 yr old) with high clinical suspicion for this disease. With a moderate level of evidence, this meta-analysis confirms that nNO testing using velum closure maneuvers has diagnostic accuracy similar to EM and/or genetic testing for PCD when cystic fibrosis is ruled out. Thus, low nNO values accompanied by an appropriate clinical phenotype could be used as a diagnostic PCD test, though EM and/or genetics will continue to provide confirmatory information.

Application of the GRADE Approach in the Development of Guidelines and Recommendations in Genomic Medicine

A great deal of ambiguity exists in the development of guidelines for genomic applications used in clinical practice. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has the potential to be applied in the guidelines and recommendations development process in genomics. Here, we discuss whether and how GRADE can be applied to address the challenges posed by the evidence-based guidelines and recommendations development process in genomics. To see how GRADE can complement to the current guidelines development in genomics, we compare and contrast GRADE with other approaches. GRADE differed from other methods by incorporating patient values and preferences and balance of consequences. We conclude that the groups trying to implement genomics into practice may gleam more information from applying the GRADE framework. However, it is not clear yet whether GRADE can address the issue of timeliness in terms of the differences between the time required for guidelines development and the rapid pace of genomics.

Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series

The GRADE-CERQual ('Confidence in the Evidence from Reviews of Qualitative research') approach provides guidance for assessing how much confidence to place in findings from systematic reviews of qualitative research (or qualitative evidence syntheses). The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. Confidence in the evidence from qualitative evidence syntheses is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. CERQual provides a systematic and transparent framework for assessing confidence in individual review findings, based on consideration of four components: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. A fifth component, dissemination (or publication) bias, may also be important and is being explored. As with the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach for effectiveness evidence, CERQual suggests summarising evidence in succinct, transparent, and informative Summary of Qualitative Findings tables. These tables are designed to communicate the review findings and the CERQual assessment of confidence in each finding. This article is the first of a seven-part series providing guidance on how to apply the CERQual approach. In this paper, we describe the rationale and conceptual basis for CERQual, the aims of the approach, how the approach was developed, and its main components. We also outline the purpose and structure of this series and discuss the growing role for qualitative evidence in decision-making. Papers 3, 4, 5, 6, and 7 in this series discuss each CERQual component, including the rationale for including the component in the approach, how the component is conceptualised, and how it should be assessed. Paper 2 discusses how to make an overall assessment of confidence in a review finding and how to create a Summary of Qualitative Findings table. The series is intended primarily for those undertaking qualitative evidence syntheses or using their findings in decision-making processes but is also relevant to guideline development agencies, primary qualitative researchers, and implementation scientists and practitioners.

[Evaluation of Efficiencies on the Gadoxetic Acid-enhanced MRI for Preoperative Assessment of Liver Metastases from Colorectal Carcinoma]

THE AIMS OF OUR STUDY WERE

1) to evaluate efficiencies of gadoxetic acid-enhanced magnetic resonance imaging (Gd-EOB-MRI) for preoperative assessment of liver metastases from colorectal carcinoma, and 2) to compare them with other diagnostic imaging modalities. The subjects of the analysis were outpatients with advanced colorectal cancer who are at risk of developing liver metastases (initial setting: pre-test probability=20%). At initial setting, we performed a decision analysis to calculate numbers of true positive (TP), false negative (FN), false positive (FP) and true negative (TN) test results per 1000 patients of Gd-EOB-MRI and other imaging modalities (conventional contrast agent-enhanced MRI, contrast-enhanced CT and ¹⁸F-FDG PET/CT). From the result of decision analysis, we calculated the cost of detection per one patient with liver metastases (detection cost). Also, we calculated positive predictive value (PPV) and negative predictive value (NPV). Moreover, these values were defined as efficiencies in this study. In the initial setting, number of TP, FN, FP TN results and detection cost of Gd-EOB-MRI were 197, 3, 40, 760, and 224,032.8 Japanese Yen, respectively. Also, PPV and NPV were 83.1% and 99.7%, respectively. In comparison with other imaging modalities, efficiencies of Gd-EOB-MRI were superior to them, except detection cost. We consider that the efficiencies of Gd-EOB-MRI, which we had assessed are easy to understand and useful when they are used for explanation to patients.

The global impact of the DRACMA guidelines cow's milk allergy clinical practice

BACKGROUND

The 2010 Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines are the only Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for cow's milk allergy (CMA). They indicate oral food challenge (OFC) as the reference test for diagnosis, and suggest the choice of specific alternative formula in different clinical conditions. Their recommendations are flexible, both in diagnosis and in treatment.

OBJECTIVES & METHODS

Using the Scopus citation records, we evaluated the influence of the DRACMA guidelines on milk allergy literature. We also reviewed their impact on successive food allergy and CMA guidelines at national and international level. We describe some economic consequences of their application.

RESULTS

DRACMA are the most cited CMA guidelines, and the second cited guidelines on food allergy. Many subsequent guidelines took stock of DRACMA's metanalyses adapting recommendations to the local context. Some of these chose not to consider OFC as an absolute requirement for the diagnosis of CMA. Studies on their implementation show that in this case, the treatment costs may increase and there is a risk of overdiagnosis. Interestingly, we observed a reduction in the cost of alternative formulas following the publication of the DRACMA guidelines.

CONCLUSIONS

DRACMA reconciled international differences in the diagnosis and management of CMA. They promoted a cultural debate, improved clinician's knowledge of CMA, improved the quality of diagnosis and care, reduced inappropriate practices, fostered the efficient use of resources, empowered patients, and influenced some public policies. The accruing evidence on diagnosis and treatment of CMA necessitates their update in the near future.

American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children

INTRODUCTION

The purpose of this position paper is to establish the American Academy of Sleep Medicine's (AASM) position on the use of a home sleep apnea test (HSAT) for the diagnosis of obstructive sleep apnea (OSA) in children (birth to 18 years of age).

METHODS

The AASM commissioned a task force of 8 experts in sleep medicine to review the available literature on the use of an HSAT to diagnose OSA in children. The task force developed the position statement based on a thorough review of these studies and their clinical expertise. The AASM Board of Directors approved the final position statement.

POSITION STATEMENT

Use of a home sleep apnea test is not recommended for the diagnosis of obstructive sleep apnea in children. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.

[GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction]

Clinicians, guideline developers, and policymakers sometimes neglect important criteria, give undue weight to criteria, and do not use the best available evidence to inform their judgments. Explicit and transparent systems for decision making can help to ensure that all important criteria are considered and that decisions are informed by the best available research evidence. The GRADE Working Group has developed Evidence to Decision (EtD) frameworks for the different type of recommendations or decisions. The purpose of EtD frameworks is to help people use evidence in a structured and transparent way to inform decisions in the context of clinical recommendations, coverage decisions, and health system or public health recommendations and decisions. EtD frameworks have a common structure that includes formulation of the question, an assessment of the evidence, and drawing conclusions, though there are some differences between frameworks for each type of decision. EtD frameworks inform users about the judgments that were made and the evidence supporting those judgments by making the basis for decisions transparent to target audiences. EtD frameworks also facilitate dissemination of recommendations and enable decision makers in other jurisdictions to adopt recommendations or decisions, or adapt them to their context. This article is a translation of the original article published in British Medical Journal. The EtD frameworks are currently used in the Clinical Practice Guideline Programme of the Spanish National Health System, co-ordinated by GuíaSalud.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES

Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

METHODS

Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

Head-to-head comparison of procalcitonin and presepsin for the diagnosis of sepsis in critically ill adult patients: a protocol for a systematic review and meta-analysis

INTRODUCTION

Early diagnosis and immediate therapeutic intervention, including appropriate antibiotic therapy and goal-directed resuscitation, are necessary to reduce mortality in patients with sepsis. However, a single clinical or biological marker indicative of sepsis has not been adopted unanimously. Although procalcitonin and presepsin are promising biomarkers that can effectively differentiate between sepsis/infection and systemic inflammatory response syndrome of non-infectious origin, little is known about which marker is superior.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of procalcitonin and presepsin for the diagnosis of sepsis/infection in critically ill adult patients. The primary objective is to evaluate the diagnostic accuracy of these 2 biomarkers to a reference standard of sepsis/infection and to compare the diagnostic accuracy with each other. We will search electronic bibliographic databases such as MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials for retrospective and prospective diagnostic test studies. We will assign 2 reviewers to review all collected titles and associated abstracts, review full articles, and extract study data. We will use the Quality of Diagnostic Accuracy Studies-II tool to report study characteristics and to evaluate methodological quality. If pooling is possible, we will use bivariate random effects and hierarchical summary receiver operating characteristic (ROC) models to calculate parameter estimates to output summary ROCs, pooled sensitivity and specificity data, and 95% CIs around the summary operating point. We will also assess heterogeneity via clinical and methodological subgroup and sensitivity analyses.

ETHICS AND DISSEMINATION

This systematic review will provide guidance on the triage of these tests, help to determine whether existing tests should be revised or replaced, and may also identify knowledge gaps in sepsis diagnosis that could direct further research in the field. Research ethics is not required for this review. The findings will be reported at conferences and in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

CRD42016035784.

ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula

BACKGROUND

Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA.

METHODS

Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

Systematic review of the accuracy of antibody tests used to screen asymptomatic adults for hepatitis C infection

BACKGROUND

Several expert groups, including the United States Preventive Services Task Force and the Canadian Task Force on Preventive Health Care, have recently examined or are currently examining whether primary care physicians should screen asymptomatic adults for hepatitis C virus (HCV) infection. To inform decision-making on HCV screening, we performed a systematic review of the accuracy of antibody tests compared with other immunoassays and RNA detection for screening asymptomatic adults for HCV infection in Canada.

METHODS

MEDLINE and Embase databases were searched from 1990 to 2016; resulting citations were uploaded into DistillerSR and independently screened by 2 reviewers. Original research studies, systematic reviews and meta-analyses were eligible for inclusion. At least 80% of the study population had to be asymptomatic, nonpregnant, treatment-naïve adults with unknown liver enzyme values and unknown HCV status. Risk of bias was assessed with the use of the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2) tool; the quality of the body of evidence was assessed by means of GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.

RESULTS

Of 1537 articles identified, 81 underwent full-text review, and 9 studies met the inclusion criteria. Compared with RNA detection, the sensitivity of the third-generation enzyme-linked immunosorbent assay was variable (61.0%-81.8%), and its specificity was high (97.5%-99.7%). As expected, there were more false-positive results when comparing antibody tests to RNA detection than to other immunoassays. Our GRADE assessment suggested that there was a high concern for risk of bias, particularly verification bias, and substantial inconsistency between studies in terms of their design.

INTERPRETATION

More research is needed to better characterize the accuracy of antibody tests used to screen for HCV infection in the general population. Jurisdictions that recently adopted birth cohort screening for HCV infection are encouraged to evaluate and report on the accuracy of HCV screening tests and screening benefits and harms. PROSPERO registration: no. CRD42016039710.

Imaging Guidelines for Enhancing Justifications for Radiologic Studies

Justification in the field of radiology refers to the appropriate use of radiologic imaging modalities, and may be achieved by establishing clinical imaging guidelines (CIGs). Recently, CIGs have been shown to be useful in selecting the proper medical imaging modality, resulting in the reduction of inappropriate radiologic examinations, thereby enhancing justifications. However, the development of CIGs is both time-consuming and difficult as the methodology of evidence-based medicine should be adhered to. Thus, although the radiologic societies in developed countries such as the United Kingdom and USA are already developing and implementing CIGs in their clinical practices, CIGs are not yet readily available in many other countries owing to differences in medical circumstances and resources. In this review, we assess the role and limitations of CIGs by examining the current status of CIGs in developed countries, and also describe the specific efforts made to establish CIGs in Korea.

HIV testing updates and challenges: when regulatory caution and public health imperatives collide

Numerous improvements in HIV testing technology led recently to the first revision of recommendations for diagnostic laboratory testing in the USA in 25 years. Developments in HIV testing continue to produce tests that identify HIV infection earlier with faster turnaround times for test results. These play an important role in identifying HIV infection during the highly infectious acute phase, which has implication for both patient management and public health interventions to control the spread of HIV. Access to these developments, however, is often delayed by the regulatory apparatus for approval and oversight of HIV testing in the USA. This article summarizes recent developments in HIV diagnostic testing technology, outlines their implications for clinical management and public health, describes current systems of regulatory oversight for HIV testing in the USA, and proposes alternatives that could expedite access to improved tests as they become available.

Developing GRADE outcome-based recommendations about diagnostic tests: a key role in laboratory medicine policies

Harmonisation and risk management policies represent key-issues in modern laboratory medicine as they focus on a more patient-centred delivery of laboratory information based on the recognition of the importance of all steps of the total testing process (TTP) for assuring quality and patient safety. However, a further essential step in project aiming to improve the value of laboratory medicine becomes the assessment of the impact of testing on patient-important outcomes. The grading of recommendations assessment, development and evaluation (GRADE) evidence to decision (EtD) frameworks may provide a systematic and transparent approach for translating the best clinical evidence available into healthcare decisions and recommendations. GRADE is a tool appropriate not only for evaluating test accuracy but also for clinical impact, such as mortality, morbidity, symptoms, and quality of life and therefore it should be applied to the outcome research in laboratory medicine. The application of GRADE requires the recognition that a recommendation about the use of test results should result from a balance between the desirable and the undesirable consequences, including non-health related consequences such as resource utilisation, feasibility, acceptability, equity and other factors. GRADE EtDs, represents a fundamental step in projects designed to improve care quality. Patient-physician-laboratory feedback can be assured through the GRADE process, where the team developing the recommendations should include the “three-parties” representatives; clinicians, laboratorians and patient/consumers. This ensures that the laboratory-patient interaction should not be a one-way process only (information from laboratory to patient) but a two-way process, incorporating patient expectations and feedback.

Grading Evidence for Laboratory Test Studies Beyond Diagnostic Accuracy: Application to Prognostic Testing

BACKGROUND

Evidence-based guideline development requires transparent methodology for gathering, synthesizing and grading the quality and strength of evidence behind recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) project has addressed diagnostic test use in many of their publications. Most of the work has been directed at diagnostic tests and no consensus has been reached for prognostic biomarkers.

AIM OF THIS PAPER

The GRADE system for rating the quality of evidence and the strength of a recommendation is described. The application of GRADE to diagnostic testing is discussed and a description of application to prognostic testing is detailed. Some strengths and limitations of the GRADE process in relation to clinical laboratory testing are presented.

CONCLUSIONS

The GRADE system is applicable to clinical laboratory testing and if correctly applied should improve the reporting of recommendations for clinical laboratory tests by standardising the style of recommendation and by encouraging transparent reporting of the actual guideline process.

Insertion torque recordings for the diagnosis of contact between orthodontic mini-implants and dental roots: protocol for a systematic review

BACKGROUND

Hitting a dental root during the insertion of orthodontic mini-implants (OMIs) is a common adverse effect of this intervention. This condition can permanently damage these structures and can cause implant instability. Increased torque levels (index test) recorded during the insertion of OMIs may provide a more accurate and immediate diagnosis of implant-root contact (target condition) than radiographic imaging (reference standard). An accurate index test could reduce or eliminate X-ray exposure. These issues, the common use of OMIs, the high prevalence of the target condition, and because most OMIs are placed between roots warrant a systematic review. We will assess 1) the diagnostic accuracy and the adverse effects of the index test, 2) whether OMIs with root contact have higher insertion torque values than those without, and 3) whether intermediate torque values have clinical diagnostic utility.

METHODS

The Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 statement was used as a the guideline for reporting this protocol. Inserting implants deliberately into dental roots of human participants would not be approved by ethical review boards and adverse effects of interventions are generally underreported. We will therefore apply broad spectrum eligibility criteria, which will include clinical, animal and cadaver models. Not including these models could slow down knowledge translation. Both randomized and non-randomized research studies will be included. Comparisons of interest and subgroups are pre-specified. We will conduct searches in MEDLINE and more than 40 other electronic databases. We will search the grey literature and reference lists and hand-search ten journals. All methodological procedures will be conducted by three reviewers. Study selection, data extraction and analyses, and protocols for contacting authors and resolving conflicts between reviewers are described. Designed specific risk of bias tools will be tailored to the research question. Different research models will be analysed separately. Parameters for exploring statistical heterogeneity and conducting meta-analyses are pre-specified. The quality of evidence for outcomes will be assessed through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

The findings of this systematic review will be useful for patients, clinicians, researchers, guideline developers, policymakers, and surgical companies.

Benefits and limitations of laboratory diagnostic pathways

Diagnostic pathways are an essential subset of clinical pathways and a logical consequence of DRG-based reimbursement. They combine the principle of stepwise reflex and reflective testing with a management concept that helps to fulfill medical needs with organizational and economic efficacy. The two most common formats describing diagnostic pathways are graphical decision trees on paper and "if…then…else" rules on computers. From a laboratory point of view, diagnostic pathways represent "smart" test profiles, which - in contrast to conventional (inflexible) profiles - are not necessarily worked off completely, but just to a point, where a diagnostic decision can be made. This improves the cost-effectiveness of laboratory testing, while making sure that no essential tests are missed. The paper describes benefits and limitations of diagnostic pathways from a medical, organizational, and economic point of view. Their major advantage is also their major drawback, since they make the diagnostic process on the one hand extremely straight-forward and transparent, while on the other hand oversimplifying the underlying medical decision principles. This may provoke the abuse of their primarily medical intentions for mere economic purposes.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine

Objectives

To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy.

Methods

GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included.

Results and conclusions

Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48–72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-014-3470-x) contains supplementary material, which is available to authorized users.

Introduction to the GRADE approach for guideline development: considerations for physical therapist practice

BACKGROUND

Practice guidelines (guidelines) have an increasing role in health care delivery and are being published more frequently. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is an approach for guideline development. The GRADE approach has been adopted by multiple national and international organizations producing guidelines related to physical therapist care.

OBJECTIVE

The purpose of this article is to introduce physical therapists to the GRADE approach for guideline development.

RESULTS

GRADE provides a consistent approach for guideline development and transparency in the communication of how the guidelines were developed and how the recommendations were reached, leading to informed choices by patients, clinicians, and policy makers in health care. GRADE leads to a clear distinction between the strength of the evidence and the recommendation. Both the direction (for or against) and the strength (weak or strong) of the recommendation are considered. For determining the strength of the recommendation, GRADE takes into account the quality of evidence, the balance of benefit and harm, uncertainty about or variability in patients' values and preferences, and uncertainty about whether the intervention is a wise use of resources.

LIMITATIONS

The GRADE approach has been used primarily with interventions and clinical questions and less often with questions related to diagnosis and prognosis.

CONCLUSIONS

The frequency of publication of guidelines is increasing. To make informed choices in the health care system, physical therapists should understand how guidelines are developed. The GRADE approach has been adopted by national and international organizations that produce guidelines relevant to physical therapist practice. Understanding the GRADE approach will enable physical therapists to make informed clinical choices.

European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection

In 2009 the first European Society of Clinical Microbiology and Infection (ESCMID) treatment guidance document for Clostridium difficile infection (CDI) was published. The guideline has been applied widely in clinical practice. In this document an update and review on the comparative effectiveness of the currently available treatment modalities of CDI is given, thereby providing evidence-based recommendations on this issue. A computerized literature search was carried out to investigate randomized and non-randomized trials investigating the effect of an intervention on the clinical outcome of CDI. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The ESCMID and an international team of experts from 11 European countries supported the process. To improve clinical guidance in the treatment of CDI, recommendations are specified for various patient groups, e.g. initial non-severe disease, severe CDI, first recurrence or risk for recurrent disease, multiple recurrences and treatment of CDI when oral administration is not possible. Treatment options that are reviewed include: antibiotics, toxin-binding resins and polymers, immunotherapy, probiotics, and faecal or bacterial intestinal transplantation. Except for very mild CDI that is clearly induced by antibiotic usage antibiotic treatment is advised. The main antibiotics that are recommended are metronidazole, vancomycin and fidaxomicin. Faecal transplantation is strongly recommended for multiple recurrent CDI. In case of perforation of the colon and/or systemic inflammation and deteriorating clinical condition despite antibiotic therapy, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Applying Grading of Recommendations Assessment, Development and Evaluation (GRADE) to diagnostic tests was challenging but doable

OBJECTIVES

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group developed an approach to assess the quality of evidence of diagnostic tests. Its use in Cochrane diagnostic test accuracy reviews is new. We applied this approach to three Cochrane reviews with the aim of better understanding the application of the GRADE criteria to such reviews.

STUDY DESIGN AND SETTING

We selected reviews to achieve clinical and methodological diversities. At least three assessors independently assessed each review according to the GRADE criteria of risk of bias, indirectness, imprecision, inconsistency, and publication bias. Two teleconferences were held to share experiences.

RESULTS

For the interpretation of the GRADE criteria, it made a difference whether assessors looked at the evidence from a patient-important outcome perspective or from a test accuracy standpoint. GRADE criteria such as inconsistency, imprecision, and publication bias were challenging to apply as was the assessment of comparative test accuracy reviews.

CONCLUSION

The perspective from which evidence is graded can influence judgments about quality. Guidance on application of GRADE to comparative test reviews and on the GRADE criteria of inconsistency, imprecision, and publication bias will facilitate the operationalization of GRADE for diagnostics.

A survey of FDG- and amyloid-PET imaging in dementia and GRADE analysis

PET based tools can improve the early diagnosis of Alzheimer's disease (AD) and differential diagnosis of dementia. The importance of identifying individuals at risk of developing dementia among people with subjective cognitive complaints or mild cognitive impairment has clinical, social, and therapeutic implications. Within the two major classes of AD biomarkers currently identified, that is, markers of pathology and neurodegeneration, amyloid- and FDG-PET imaging represent decisive tools for their measurement. As a consequence, the PET tools have been recognized to be of crucial value in the recent guidelines for the early diagnosis of AD and other dementia conditions. The references based recommendations, however, include large PET imaging literature based on visual methods that greatly reduces sensitivity and specificity and lacks a clear cut-off between normal and pathological findings. PET imaging can be assessed using parametric or voxel-wise analyses by comparing the subject's scan with a normative data set, significantly increasing the diagnostic accuracy. This paper is a survey of the relevant literature on FDG and amyloid-PET imaging aimed at providing the value of quantification for the early and differential diagnosis of AD. This allowed a meta-analysis and GRADE analysis revealing high values for PET imaging that might be useful in considering recommendations.

From evidence to best practice in laboratory medicine

Laboratory tests offer value if they provide benefit to patients at acceptable costs. Laboratory testing is one of the most widely used diagnostic interventions supporting medical decisions, yet evidence demonstrating its value and impact on health outcomes is limited. This contributes to wide variations in test utilisation including underdiagnosis, overdiagnosis and misdiagnosis, which may impact the quality and the clinical- and cost-effectiveness of care and patient safety. Therefore implementing evidence into the care of patients is a moral and social imperative to laboratory professionals and all health care staff. This review investigates the reasons research does not get into practice, or only does with a very long delay. Apart from reviewing the common barriers to implementation, it also discusses the drivers of inappropriate test utilisation. By reviewing the theoretical and practical aspects of implementation science, recommendations are made for approaches that are thought to be most effective and that can be adopted to close the gap between evidence and practice, and to facilitate evidence-based laboratory medicine. Passive dissemination of the evidence and educational interventions are insufficient and do not offer sustainable solutions. A multifaceted and individualised implementation strategy, including individually tailored academic detailing, reminder systems, clinical decision support systems, feedback on performance, and participation of doctors and laboratory professionals in quality improvement activities addressing test selection and interpretation and in clinical audits, has greater potential for success. Examples of these initiatives at the laboratory and clinical interface are provided with links to valuable resources.

Deciding what type of evidence and outcomes to include in guidelines: article 5 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report

INTRODUCTION

Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the fifth of a series of 14 articles that were prepared by an international panel to advise guideline developers in respiratory and other diseases on approaches for guideline development. This article focuses on what type of evidence and outcomes to include in guidelines.

METHODS

In this review we addressed the following topics and questions. (1) What methods should be used to select important outcomes? (2) What types of outcomes should be considered? (3) What sources of evidence should be considered? (4) How should the importance of outcomes be ranked? (5) How to deal with surrogate outcomes. (6) What issues related to outcomes should be considered in the evidence review? (7) What quality of evidence should be used? (8) How to interpret the effect on outcomes. (9) How to incorporate outcomes related to harm. We based our responses on a PubMed literature review, prior reviews, relevant methodological research, and workshop discussions.

RESULTS AND DISCUSSION

Guideline panels should use transparent and systematic methods to select both the evidence and important outcomes, with input from groups that represent a wide range of expertise and constituencies. Outcomes should address both benefits and downsides, with consideration of the definitions, severity, and time course of the outcomes. Guideline panels should use a transparent approach to rank outcome importance recognizing that stakeholder and patient values and preferences may vary. Intermediate and surrogate outcomes are frequently reported, but their correlation with patient important outcomes may be low. A guideline panel should determine a priori the magnitude of effect judged clinically significant, factors that may influence outcome reporting, and whether different ways of measuring the outcomes permit the outcomes to be combined. Comprehensive identification of the evidence includes the use of multiple data sources. While randomized controlled trials (RCTs) provide the highest quality evidence, reviewers of evidence also need to consider nonrandomized studies such as case series, registries, and case-control studies if randomized trials are not available. This is particularly true for harms. The outcomes reported from RCTs may not always directly apply to clinical practice settings (i.e., they may not be generalizable).

Guidelines for guideline developers: a systematic review of grading systems for medical tests

BACKGROUND

A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent. We compared grading systems for medical tests on how they use evidence in guideline development.

METHODS

We used a systematic strategy to look for grading systems specific to medical tests in PubMed, professional guideline websites, via personal correspondence, and handsearching back references of key articles. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument as a starting point, we defined two sets of characteristics to describe these systems: methodological and process ones. Methodological characteristics are features relating to how evidence is gathered, appraised, and used in recommendations. Process characteristics are those relating to the guideline development process. Data were extracted in duplicate and differences resolved through discussion.

RESULTS

Twelve grading systems could be included. All varied in the degree to which methodological and process characteristics were addressed. Having a clinical scenario, identifying the care pathway and/or developing an analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these, to varying degrees of explicitness and completeness. Process wise, features most frequently addressed included involvement of relevant professional groups (8/12), external peer review of completed guidelines (9/12), and recommendations on methods for dissemination (8/12). Characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12).

CONCLUSIONS

Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

Ask the right question: a critical step for practicing evidence-based laboratory medicine

The purpose of laboratory medicine is to facilitate better decision making in clinical practice and healthcare delivery. Decision making implies an unresolved issue, problem or unmet need. The most important criterion for any investigation to be of value in clinical practice is that it addresses an unmet need. The different ways in which laboratory investigations are utilized in patient care can be represented in the form of questions. It is important that these questions are articulated to highlight the variables that will impact on the effectiveness of the investigation in the scenario being considered. These variables include the characteristics of the patient (or population) and clinical setting, the nature of the decision and action taken on receipt of the test result and the expected outcome. Asking a question is the first step of the evidence-based laboratory medicine (EBLM) cycle, the other steps being acquiring the evidence, critically appraising the evidence, applying the evidence and auditing use of the evidence. Getting the question right determines the quality of the whole process, thus, defines the quality in practice of laboratory medicine. Whilst the main focus of the EBLM cycle is to provide a strong evidence base for use in clinical practice, it is clear that the five steps are equally applicable in commissioning, delivery and audit (performance management) of services. Asking the right question is crucial to improving the quality of evidence, and practice, in laboratory medicine, and should be used in routine laboratory medicine practice and management throughout healthcare.

Acupuncture for Treating Anxiety and Depression in Women: A Clinical Systematic Review

BACKGROUND

Anxiety and depression are high in prevalence, especially in the female population, whose incidence is approximately double that of the male population. In addition, these conditions are difficult to treat and have high relapse rates and medication side-effects. There is evidence to suggest that acupuncture may be an effective treatment modality.

OBJECTIVE

The aim of this review is to summarize the existing evidence on acupuncture as a therapy for anxiety and depression in women and to present a novel method for assessing acupuncture trial quality.

METHODS

Published randomized controlled trials were included, whereby acupuncture was compared with any control procedure in subjects with anxiety and/or depression. Two authors extracted data independently. A novel acupuncture trial quality-assessment tool was developed to analyze the literature quality.

RESULTS

Six articles used the desired inclusion and exclusion criteria. The quality of research varied heavily. Five studies were properly randomized. Three were double-blinded. Three used individualized acupuncture. Four studies were of at least reasonable quality. One was of marginal quality, and one was of poor quality. There was a significant difference between acupuncture and at least one control in all six trials.

CONCLUSIONS

With respect to six reviewed studies, there is high-level evidence to support the use of acupuncture for treating major depressive disorder in pregnancy.

SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis

OBJECTIVE

Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU.

PARTICIPANTS

Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations.

CONCLUSIONS

Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.

How DRACMA changes clinical decision for the individual patient in CMA therapy

PURPOSE OF REVIEW

To describe the impact of the diagnosis and rationale for action against cow's milk allergy (DRACMA) guidelines on the decision process in the therapy of cow's milk allergy (CMA).

RECENT FINDINGS

We report here the experience of a 2-year application of DRACMA worldwide. Variations in the socioeconomic profile of CMA sufferers and their context can modify the application of DRACMA recommendations. As an example, we use the country-by-country modifications of the social structure and the modifications of the prices for special formula in Italy.

SUMMARY

The DRACMA guidelines were issued to inform formula choice for CMA treatment by integrating patients' underlying values, preferences and remarks into grading of recommendations assessment, development and evaluation (GRADE) recommendations, which serve to facilitate their interpretation. This method allows every pediatrician/allergist to follow the changing variables of formulas (cost, palatability, nutritional value) and tailor their prescription for individual patients accordingly. The art of CMA treatment has always relied on physicians' interpretation and the goal of the DRACMA guidelines is to provide a rationale-based and evidence-based indication for choosing an appropriate formula.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.