[Integrative assessment of evidence in healthcare: the GRADE system]

[Pharmacotherapy of chronic neuropathic pain]

Chronic neuropathic pain has a prevalence of 6.9-10% in the general population. The current recommendations for treatment are presented based on a literature search. Neuropathic pain requires the use of co-analgesic, antidepressant, anticonvulsant drugs and topical agents because non-opioid analgesic drugs are usually ineffective. The use of meta-analyses tricyclic antidepressants, selective serotonin-norephinephrine reuptake inhibitors, and calcium channel anticonvulsants are recommended as the drugs of first choice. Under certain conditions chronic neuropathic pain can be treated with opioids. Topical therapeutics are only used to treat peripheral neuropathic pain. At present the use of drugs is independent of the etiology of the pain. Comorbidities, concomitant medication, potential side effects and patients' age have to be considered in treatment planning.

Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency

BACKGROUND

Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care).

METHODS

This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus.

RESULTS

Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate).

CONCLUSION

Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.

The Pharmacological Therapy of Chronic Neuropathic Pain

BACKGROUND

Chronic neuropathic pain, including painful peripheral polyneuropathy and post-herpetic neuralgia, affects 6.9-10% of the general population.

METHODS

In this article, we present current treatment recommendations on the basis of a selective review of the literature.

RESULTS

Neuropathic pain does not respond consistently to classic non-opioid analgesic drugs and is better treated with co-analgesic, antidepressant, and anticonvulsant drugs and topical agents. Under certain conditions, however, neuropathic pain can be treated with opioids, even chronically. It was concluded in a large-scale m eta- analysis that tricyclic antidepressants, selective serotonin- norepinephrine reuptake inhibitors, and calcium-channel anticonvulsants are the drugs of first choice, with a number needed to treat (NNT) of 3.5-7.7 for a 50% reduction of pain. An analysis of all studies yielded an estimated publication bias of 10%. Treatment planning must include adequate consideration of the patient's age and comorbidities, concomitant medication, and potential side effects.

CONCLUSION

Drugs are now chosen to treat neuropathic pain independently of the cause and symptoms of the pain. Topical agents are used only to treat peripheral neuropathy. The utility of a treatment approach based on the patient's symptoms and pathological mechanisms was recently demonstrated for the first time in a randomized trial. The goal of current research is to facilitate treatment planning on the basis of the clinical phenotype.

Systematic evaluation of the quality of clinical practice guidelines on the use of assisted reproductive techniques

OBJECTIVE

To conduct a systematic evaluation of clinical practice guidelines (CPGs) on the use of assisted reproductive technologies.

METHODS

We searched Medline, the Turning Research into Practice database, and guidelines-specific databases from December 2006 to November 2011. Three reviewers independently assessed each Guideline using the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument. A standardized score was calculated separately for each of the six domains.

RESULTS

Fourteen Guidelines were included. Overall, the quality of these was suboptimal. The scores for each AGREE II domain ranged between 37% and 80%. Three (22%) were deemed "Recommended"; nine (64%),"Recommended with modifications"; and two (14%), "Not recommended". Agreement among reviewers was very good (Intraclass Correlation Coefficient: 0.915 [95% CI 0.807-0.970]).

CONCLUSIONS

The overall quality of the CPGs on Assisted Reproduction Techniques published during the last 5 years is suboptimal. Most Guidelines present significant shortcomings in important domains such as "stakeholder involvement", "rigor of development", and "applicability". Instruments such as the AGREE II and "the Grading of Recommendation Assessment Development and Evaluation" system could prove useful to improve CPGs in this field. Guideline users could benefit from the present results when choosing which guidelines to implement.

Does the pharmaceutical industry influence guidelines?: two examples from Germany

BACKGROUND

The recommendations in clinical guidelines are based on clinical trial findings and expert opinion. The influence of drug companies on these two factors is illustrated with two examples.

METHODS

A judicially ordered expert review revealed that the market authorization holder (MAH) of gabapentin manipulated study data. Gabapentin was, therefore, chosen as an example for this article to analyze whether manipulated data serve as a basis for recommendations in German clinical guidelines. A search was carried out for manipulated publications on gabapentin that found their way into guidelines published by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). To analyze the possible effects of financial ties between guideline authors and drug companies, the S3 guideline on the treatment of psoriasis vulgaris with efalizumab was compared with guidelines whose authors had no conflicts of interest. One of the authors of this article had noted variable prescribing practices for psoriasis among dermatologists while carrying out an economic assessment for a German state Association of Statutory Health Insurance Physicians.

RESULTS

The data that had been manipulated by the MAH of gabapentin served as a basis for recommendations to prescribe gabapentin in guidelines that were published by the AWMF. Efalizumab was judged more favorably in the S3 guideline than in a guideline issued by the National Institute of Health and Care Excellence: for example, the evidence for it was judged as good, the use of efalizumab for induction and combination therapy in psoriasis vulgaris was recommended, and efalizumab was said to improve patients' health-related quality of life.

CONCLUSION

Public access to all trial data must be ensured so that independent evaluations are possible. We take the view that the responsibility for creating guidelines should be borne by authors and organizations that do not have any conflicts of interest.

[GRADE guidelines: 1. Introduction - GRADE evidence profiles and summary of findings tables]

This article is the first of a series providing guidance for the use of the GRADE system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments, and clinical practice guidelines addressing alternative management options. The GRADE process begins with asking an explicit question, including specification of all important outcomes. After the evidence has been collected and summarised, GRADE provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations are characterised as strong or weak (alternative terms: conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of the alternative management options. GRADE suggests summarising evidence in succinct, transparent, and informative Summary of Findings tables that show the quality of evidence and the magnitude of relative and absolute effects for each important outcome and/or as evidence profiles that provide, in addition, detailed information about the reason for the quality of evidence rating. Subsequent articles in this series will address GRADE's approach to formulating questions, assessing quality of evidence, and developing recommendations.

Interdisziplinäre S3-Leitlinien für substanzbezogene Störungen

Hintergrund: Im Jahr 2006 wurde erstmals eine deutsche evidenzbasierte Leitlinie für substanzbezogene Störungen veröffentlicht. Seitdem hat sich der Kenntnisstand bezüglich des Screenings, der Diagnostik und der Therapie von Suchterkrankungen verbessert. Ziel: Das aktuellste, internationale Wissen über evidenzbasierte Interventionen für alkohol- und tabakbezogenen Störungen soll zusammengefasst, Empfehlungen für die Praxis sollen abgeleitet und abgestimmt werden. Methode: Um Leitlinien der methodischen Qualität S3 im Rahmen der Arbeitsgemeinschaft Wissenschaftlich Medizinischer Fachgesellschaften (AWMF) zu entwickeln, erfolgt 1.) eine systematische Recherche, Auswahl und methodische Bewertung der internationalen Literatur, 2.) eine strukturierte Konsensfindung und 3.) die interdisziplinäre und repräsentative Beteiligung von über 50 Fachgesellschaften, Berufs-, Betroffenen- und Angehörigenverbänden sowie 70 Fachexperten. Ergebnisse: Die Fertigstellung der beiden S3-Leitlinien „Alkohol“ und „Tabak“ ist für das Jahr 2013 geplant. Danach sollen weitere substanzspezifische Leitlinien entwickelt werden. Alle Leitlinien sollen in regelmäßigem Abstand überarbeitet werden, um die Aktualität der klinischen Empfehlungen zu garantieren. Schlussfolgerungen: Die S3-Leitlinien sollen Therapeuten, Betroffenen und Angehörigen eine Entscheidungshilfe bei der Behandlung von Abhängigkeitserkrankungen zur Verfügung stellen.

Effectiveness of Helicobacter pylori eradication in chronic urticaria: evidence-based analysis using the Grading of Recommendations Assessment, Development, and Evaluation system

PURPOSE OF REVIEW

Chronic urticaria is a common and often frustrating condition that physicians encounter in the outpatient setting. Its management continues to be a challenge, and an exogenous cause for chronic urticaria is only found rarely. Helicobacter pylori has been implicated as a factor for many disorders and proposed as an etiologic factor for chronic urticaria. We aim to provide a comprehensive review of the data on H. pylori eradication for treatment of chronic urticaria by utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to analyze and determine the quality of evidence for this proposed therapy.

RECENT FINDINGS

Although H. pylori eradication has been recommended as part of routine chronic urticaria management by multiple authors, the trials of H. pylori eradication in the treatment of chronic urticaria have yielded conflicting results and suffer from substantial methodological limitations.

SUMMARY

Our critical appraisal of the 10 trials showing the benefit of H. pylori eradication in patients with chronic urticaria leads to an overall very low grade for this intervention. Appraisal of nine studies in which H. pylori eradication showed no benefit in the course of chronic urticaria also leads to an overall very low grade. The evidence that H. pylori eradication leads to improvement of chronic urticaria outcomes is weak and conflicting; this leads to a weak recommendation for routine H. pylori eradication for patients with chronic urticaria. For this reason, a decision to proceed with this management should be considered carefully in the context of relative harms/burdens and benefits, as well as patient values and preferences.

[GRADE: from grading the evidence to developing recommendations. A description of the system and a proposal regarding the transferability of the results of clinical research to clinical practice]

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group represents an international collaboration of guideline developers, clinicians, health services researchers and methodologists. Many leading organizations, including the World Health Organization (WHO), use the GRADE approach because it has led to progress in the assessment of evidence and in the development of healthcare recommendations. The GRADE system distinguishes the quality of evidence from the strength of a recommendation. The quality of evidence reflects the extent of confidence that an estimate of effect is correct if it is used in the context of single endpoints. In the context of giving guidance, it reflects the extent to which confidence in an estimate of the effect is adequate to support recommendations. The strength of a recommendation, separated into strong and weak or conditional recommendations for or against an intervention, is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh the undesirable effects. A recommendation for action requires consideration for the magnitude of the expected benefit and downsides of an intervention for all patient-important endpoints, the associate values and preferences and resource use. The GRADE system includes a systematic approach to evaluate the generalizability of study results to healthcare practice. Judgments about generalizability, better termed directness, are separated into judgments about the availability of direct comparisons between two alternative management strategies and judgments about differences between the population, intervention, comparator to the intervention, and outcomes (PICO) of interest for a given question, and those included in the relevant studies. In addition to providing an overview of the GRADE system, this article focuses on the approach to assessing directness or generalizability.