Methodological and users' surveys on the use of the LILACS database in Cochrane reviews identified desirable improvements to the database

BACKGROUND

Latin American and Caribbean Health Sciences Literature (LILACS) is the main reference database in the region; however, the way in which this resource is used in Cochrane systematic reviews has not been studied.

OBJECTIVES

To assess the search methods of Cochrane reviews that used LILACS as a source of information and explore the Cochrane community's perceptions about this resource.

METHODS

We identified all Cochrane reviews of interventions published during 2019, which included LILACS as a source of information, and analysed their search methods and also ran a survey through the Cochrane Community.

RESULTS

We found 133 Cochrane reviews that reported the full search strategies, identifying heterogeneity in search details. The respondents to our survey highlighted many areas for improvement in the use of LILACS, including the usability of the search platform for this purpose.

DISCUSSION

The use and reporting of LILACS in Cochrane reviews demonstrate inconsistencies, as evidenced by the analysis of search reports from systematic reviews and surveys conducted among members of the Cochrane community.

CONCLUSION

With better guidance on how LILACS database is structured, information specialists working on Cochrane reviews should be able to make more effective use of this unique resource.

Anticancer Drugs Compared to No Anticancer Drugs in Patients with Advanced Hepatobiliary Cancer: A Mapping Review and Evidence Gap Map

Introduction

Despite being commonly recommended, the impact of anticancer drugs (ACDs) on patient-important outcomes beyond survival for advanced hepatobiliary cancers (HBCs) may not have been sufficiently assessed. We aim to identify and map the evidence regarding ACDs versus best supportive care (BSC) for advanced HBCs, considering patient-centered outcomes.

Methods

In this mapping review, we included systematic reviews, randomized controlled trials, quasi-experimental, and observational studies comparing ACDs (chemotherapy, immunotherapy, biological/targeted therapy) versus BSC for advanced HBCs. We searched MEDLINE (PubMed), EMBASE (Ovid), Cochrane Library, Epistemonikos, PROSPERO and clinicaltrials.gov for eligible studies. Two reviewers performed the screening and data extraction processes. We developed evidence maps for each type of cancer.

Results

We included 87 studies (60 for advanced liver cancer and 27 for gallbladder or bile duct cancers). Most of the evidence favored ACDs for survival outcomes, and BSC for toxicity. We identified several evidence gaps for non-survival outcomes, including quality of life or quality of end-of-life care.

Discussion

Patient-important outcomes beyond survival in advanced HBCs are insufficiently assessed by the available evidence. Future studies need to address these gaps to better inform decision-making processes.

A methodological review finds mismatch between overall and pairwise overlap analysis in a sample of overviews

OBJECTIVES

Overlap of primary studies is a key methodological challenge for overviews. There are limited reports of methods used to address overlap, and there is no detailed assessment of the corrected covered area (CCA) of a representative sample of overviews. To describe the approaches used to address overlap, and to estimate the overall and pairwise CCA.

METHODS

We searched PubMed for overviews published in 2018. Two authors conducted the screening process. We described the strategy used for assessing overlap, and calculated overall and pairwise CCA for each overview.

RESULTS

We analyzed a random sample of 30 out of 89 eligible articles. Eleven did not address the overlap. Of the remainder, most frequent strategies were visual assessment and discussion of overlap as a limitation. Median overall CCA among the included overviews was 6.7%. The pairwise analysis showed that 52.8% of SR pairs had slight overlap, while 28.3% had very high overlap.

CONCLUSION

Reported strategies for addressing overlap vary considerably among overview authors. The pairwise approach for assessing the CCA revealed highly overlapped pairs of SRs in overviews with overall slight overlap and vice versa. We encourage authors to complement the overall CCA assessment with a pairwise approach.

Risperidone and aripiprazole for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVES

To assess the effectiveness and safety of risperidone and aripiprazole in children with autism spectrum disorder (ASD).

DESIGN AND SETTING

Overview of systematic reviews (SRs).

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycInfo and Epistemonikos placing no restrictions on language or date of publication.

PARTICIPANTS

Children aged 12 years or less with ASD.

INTERVENTIONS

Risperidone and aripiprazole with no dosage restrictions.

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation certainty of the evidence according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOMES MEASURED

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PATIENT AND PUBLIC INVOLVEMENT

Organisations of parents of children with ASD were involved during part of the process, participating in external revision of the final version of the report for the Chilean Ministry of Health with no additional comments (ID 757-22-L120 DIPRECE, Ministry of Health, Chile). The organisations involved were: Fundación Unión Autismo y Neurodiversidad, Federación Nacional de Autismo, Vocería Autismo del Sur, and Vocería Autismo del Norte.

RESULTS

We identified 22 SRs within the scope of this overview, of which 16 were of critically low confidence according to AMSTAR 2 and were excluded from the analysis. Both aripiprazole and risperidone were effective for reducing autism symptoms severity, repetitive behaviours, inappropriate language, social withdrawal and behavioural problems compared with placebo. The certainty of the evidence for most outcomes was moderate. Risperidone and aripiprazole are associated with metabolic and neurological adverse events. Follow-up was short termed.

CONCLUSIONS

We found that aripiprazole and risperidone probably reduce symptom severity at short-term follow-up but may also cause adverse events. High-quality and updated SRs and larger randomised controlled trials with longer term follow-up are needed on this topic.

OVERVIEW PROTOCOL

PROSPERO CRD42020206535.

[Perfectionism, academic stress and social anxiety in female medical students and the risk for eating disorders]

BACKGROUND

Both perfectionism and social anxiety have been described in patients with eating disorders (ED) and medical students. Academic stress also can increase the risk of developing ED.

AIM

To analyze the dimensions of perfectionism, social anxiety, and academic stress associated with the risk of developing ED in female medical students.

MATERIAL AND METHODS

The Multidimensional Perfectionism Scale, the Liebowitz Social Anxiety Scale, the SISCO academic stress inventory and the Eating Attitudes Test-26, were applied to 163 female medical students from all levels of the career. The groups with and without risk of ED were compared according to these variables.

RESULTS

Twenty-four percent of respondents were at risk of ED. There were significant differences between scores of perfectionism, social anxiety, and academic stress between respondents with and without risk for ED. In general, there was a significant correlation among the variables. In a multivariate analysis, the predictors of ED risk were the perception of academic stress (Odds ratio (OR) 1.09; 95% confidence intervals (CI) 1.03-1.16) and personal standards in the context of perfectionism (OR 1.16; 95% CI 1.06-1.27).

CONCLUSIONS

A substantial proportion of female medical students were at risk for ED. The risk of ED was determined mainly by academic stress and personal standards in the context of perfectionism. In this sample, social anxiety did not play a relevant role.

Mapping Chilean clinical research: a protocol for a scoping review and multiple evidence gap maps

INTRODUCTION

Clinical research broadly aims to influence decision-making in order to promote appropriate healthcare. Funding agencies should prioritise research projects according to needed research topics, methodological and cost-effectiveness considerations, and expected social value. In Chile, there is no local diagnosis regarding recent clinical research that might inform prioritisation for future research funding. This research aims to comprehensively identify and classify Chilean health research studies, elaborating evidence gap maps for the most burdensome local conditions.

METHODS AND ANALYSIS

We will search in electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, LILACS and WoS) and perform hand searches to retrieve, identify and classify health research studies conducted in Chile or by authors whose affiliations are based in Chile, from 2000 onwards. We will elaborate evidence matrices for the 20 conditions with the highest burden in Chile (according to the Global Burden of Disease 2019) selected from those defined under the General Regime of the Health Guarantees Act. To elaborate the evidence gap maps, we will consider prioritised interventions and core outcome sets. To identify knowledge gaps and estimate redundant research, we will contrast these gap maps with the available international evidence of high or moderate certainty of evidence, for each specific clinical question. For this purpose, we will search systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

ETHICS AND DISSEMINATION

No ethical approval is required to conduct this project. We will submit our results in both peer-reviewed journals and scientific conferences. We will aim to disseminate our findings through different academic platforms, social media, local press, among others. The final results will be communicated to local funding agencies and government stakeholders.

DISCUSSION

We aim to provide an accurate and up-to-date picture of the research gaps-to be filled by new future findings-and the identification of redundant research, which will constitute relevant information for local decision-makers.

Graphical Representation of Overlap for OVErviews: GROOVE tool

Overlap of primary studies among systematic reviews (SRs) are one of the main methodological challenges when conducting overviews. If not assessed properly, overlapped primary studies may mislead findings, since they may have a major influence either in qualitative analyses or in statistical weight. Moreover, overlapping SRs may represent the existence of duplicated efforts. Matrices of evidence and the calculation of the overall corrected covered area (CCA) are appropriate methods to address this issue, but they seem to be not comprehensive enough. In this article we present GROOVE (Graphical Representation of Overlap for OVErviews), an easy-to-use tool for overview authors. Starting from a matrix of evidence, GROOVE provides the number of included primary studies and SRs included in the matrix; the absolute number of overlapped and non-overlapped primary studies; and an overall CCA assessment. The tool also provides a detailed CCA assessment for each possible pair of SRs (or "nodes"), with a graphical and easy-to-read representation of these results. Additionally, it includes an advanced optional usage, incorporating structural missingness in the matrix. In this article, we show the details about how to use GROOVE, what results it achieves and how the tool obtains these results. GROOVE is intended to improve the overlap assessment by making it easier, faster, and more friendly for both authors and readers. The tool is freely available at http://doi.org/10.17605/OSF.IO/U2MS4 and https://es.cochrane.org/es/groovetool This article is protected by copyright. All rights reserved.

Non-pharmacological interventions for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVE

To assess the effectiveness of non-pharmacological interventions for the treatment of autism spectrum disorder (ASD) in children.

DESIGN

Overview of systematic reviews (SRs).

PARTICIPANTS

Children aged 12 years and under with ASD.

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Epistemonikos placing no restrictions on language or date of publication.

INTERVENTIONS

17 non-pharmacological interventions compared with placebo, no-treatment (including waiting list) or other interventions (ie, usual care, as defined by the authors of each study).

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty of the evidence (CoE) according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOME MEASURES

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PUBLIC AND PATIENT INVOLVEMENT STATEMENT

Organisations of parents of children with ASD participated in external revision of the final version of the report.

RESULTS

We identified 52 reports that were within our scope, of which 48 were excluded for various reasons. After excluding less reliable SRs, we included four SRs. Non-pharmacological interventions (ie, Early Intensive Behavioural Intervention, Applied Behaviour Analysis, Picture Exchange Communication System and Naturalistic Developmental Behavioural Interventions) may have favourable effects on some core outcomes including language, social and functioning, play or daily living skills in children with ASD (with either no GRADE assessment, very low or low CoE). In addition, we identified a lack of report for other key outcomes in the included SRs (ie, restricted, repetitive behaviour; play and sensory processing).

CONCLUSIONS

Synthesised evidence regarding the efficacy of non-pharmacological interventions for children with ASD is scarce. High-quality SRs addressing the variety of both non-pharmacological interventions and relevant outcomes are needed.

PROSPERO REGISTRATION NUMBER

CRD42020206535.

Patients' participation in government-sponsored guidelines in Latin America: a cross-sectional study

BACKGROUND

It is recommended that patients actively participate in clinical practice guideline (CPG) development, which allows consideration of their values and preferences and improves adherence to recommendations. The development of CPGs throughout Latin America is variable and diverse, and the inclusion of patients' participation is unknown.

OBJECTIVES

To evaluate the methods of patients' participation in government-sponsored CPGs in Latin America, the type of CPG development and the use of Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methods.

DESIGN

Cross-sectional study. We included CPGs developed over the last 10 years through a comprehensive hand search in official national government websites and biomedical databases.

MAIN OUTCOME MEASURE

The type of patients' participation was coded according to five predefined categories. We also report the proportion of application of GRADE methods.

RESULTS

We included 408 CPGs from 10 countries: 74% (n=303) were de novo development, 13%(n=55) used an adaptation method and 10%(n=41) used both adaptation and de novo methods. Only 45% (n=185) applied the GRADE approach, ranging from 14% (n=12) of CPGs in Brazil to 89% (n=56) of CPGs in Colombia. Only 23% (n=95) of CPGs included at least one method of patients' participation. Mexico was one of the largest CPG producers (100 CPGs), but none included methods of patients' participation; in turn, in countries with lower production of government-sponsored CPGs, patients' participation was found in almost 88%. Guidelines using the GRADE approach were more likely to use methods of patients' participation. These methods were highly variable: 46% (n=44) incorporated patients in the panel, 81% (n=77) searched for evidence about patients' values and preferences, 43% (n=39) used an external review of the draft recommendations by patients, 38% (n=36) used public comments, and 2% included other methods for stakeholders' participation.

CONCLUSION

Only one quarter of government-sponsored CPGs in the Latin American region incorporated a method for patients' participation, which varied considerably across the selected countries. These findings highlight the need to improve CPG development methods to systematically incorporate patients' values and preferences when drafting recommendations.

Introduction to network meta-analysis for evidence synthesis

This article belongs to a collaborative methodological series of narrative reviews about biostatistics and clinical epidemiology. The goal is to present basics concepts concerning the systematics reviews of multiple treatments comparisons with network meta-analysis. For clinical ques-tions with several therapeutic alternatives to be compared, the central question is how to classify or rank their effectiveness (benefit and harm) to choose the best option. The network meta-analysis aims to answer questions related to the effectiveness and safety of comparing multiple treatments by the simultaneous analysis of results raised from direct and indirect comparisons. The network geometry is the general graphical representation of the network meta-analysis and allows to understand and assess the strength of comparisons. The network meta-analysis should check several assumptions to be valid, especially the transitivity assumption, which allows assuming that there are no systematic differences among the included comparisons, except their compared interventions. Thus, it is possible to know the relative therapeutic effectiveness of each pair of interventions included in the network meta-analysis and their ranking in terms of categorization. It has been proposed to use a modified Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach considering the distinctive features of network meta-analysis to assess the certainty of the evidence for each comparison and the ranking of interventions.

Vortioxetine for generalised anxiety disorder in adults

INTRODUCTION

The currently accepted psychopharmacological treatment for generalised anxiety disorder in adults is associated with several adverse effects which threaten its acceptability. In this line, vortioxetine has been proposed as an alternative with less adverse effects in the treatment of this pathology.

METHODS

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified seven systematic reviews including five primary studies, all corresponding to randomized trials evaluating the effectiveness of vortioxetine in adult patients with generalized anxiety disorder without current treatment. We conclude that there is uncertainty whether vortioxetine increases the response to treatment or improves anxious symptoms, because the certainty of the existing evidence has been assessed as very low. Furthermore, vortioxetine may increase nausea (low certainty evidence).

Graphical representation of the body of the evidence: the essentials for understanding the evidence gap map approach

The significant increase in scientific evidence production has led to the creation of methods to facilitate evidence review and synthesis. This has turned, this has resulted in the emergence of different designs depending on the reviews objective. Evidence gap maps constitute a novel approach for literature review. They are thematic collections of a broad field of evidence, using a systematic search strategy that identifies gaps in knowledge and engages, early on, the target audience to design a friendly graphic product. Evidence maps are a tool to be considered in the roster of options available for research funders in that they are particularly useful for evidence-based decision-making and evidence-based policy development. The most commonly used formats to display the findings of evidence gap search designs are the bubble plot and the intervention-outcome framework. This article corresponds to the sixth of a series of narrative reviews on general topics of biostatistics and clinical epidemiology. The purpose of this review is to describe the principal features of evidence gap maps, highlighting their main objectives and utility, exploring the most commonly used mapping formats, and comparing this approach with other evidence synthesis designs.

Minimal clinically important difference: The basics

This article is part of a collaborative methodological series of narrative reviews on biostatistics and clinical epidemiology. This review aims to present basic concepts about the minimal clinically important difference and its use in the field of clinical research and evidence synthesis. The minimal clinically important difference is defined as the smallest difference in score in any domain or outcome of interest that patients can perceive as beneficial. It is a useful concept in several aspects since it links the magnitude of change with treatment decisions in clinical practice and emphasizes the primacy of the patients perception, affected by endless variables such as time, place, and current state of health, all of which can cause significant variability in results.

Maternal and perinatal outcomes related to COVID-19 and pregnancy: An overview of systematic reviews

Introduction

Evidence about coronavirus disease 2019 (COVID‐19) and pregnancy has rapidly increased since December 2019, making it difficult to make rigorous evidence‐based decisions. The objective of this overview of systematic reviews is to conduct a comprehensive analysis of the current evidence on prognosis of COVID‐19 in pregnant women.

Material and methods

We used the Living OVerview of Evidence (L·OVE) platform for COVID‐19, which continually retrieves studies from 46 data sources (including PubMed/MEDLINE, Embase, other electronic databases, clinical trials registries, and preprint repositories, among other sources relevant to COVID‐19), mapping them into PICO (population, intervention, control, and outcomes) questions. The search covered the period from the inception date of each database to 13 September 2020. We included systematic reviews assessing outcomes of pregnant women with COVID‐19 and/or their newborns. Two authors independently screened the titles and abstracts, assessed full texts to select the studies that met the inclusion criteria, extracted data, and appraised the risk of bias of each included systematic review. We measured the overlap of primary studies included among the selected systematic reviews by building a matrix of evidence, calculating the corrected covered area, and assessing the level of overlap for every pair of systematic reviews.

Results

Our search yielded 1132 references. 52 systematic reviews met inclusion criteria and were included in this overview. Only one review had a low risk of bias, three had an unclear risk of bias, and 48 had a high risk of bias. Most of the included reviews were highly overlapped among each other. In the included reviews, rates of maternal death varied from 0% to 11.1%, admission to intensive care from 2.1% to 28.5%, preterm deliveries before 37 weeks from 14.3% to 61.2%, and cesarean delivery from 48.3% to 100%. Regarding neonatal outcomes, neonatal death varied from 0% to 11.7% and the estimated infection status of the newborn varied between 0% and 11.5%.

Conclusions

Only one of 52 systematic reviews had a low risk of bias. Results were heterogeneous and the overlap of primary studies was frequently very high between pairs of systematic reviews. High‐quality evidence syntheses of comparative studies are needed to guide future clinical decisions.

Angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers for COVID-19: A living systematic review of randomized clinical trials

Objective

This living systematic review aims to provide a timely, rigorous, and continuously updated summary of the evidence available on the role of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) in the treatment of patients with COVID-19.

Data sources

We conducted searches in PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), grey literature and in a centralized repository in L·OVE (Living OVerview of Evidence), which retrieves articles from multiple sources such as PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, among other pre-print and protocols repositories. In response to the COVID-19 emergency, L·OVE (Living OVerview of Evidence) was adapted to expand the range of evidence and customized to group all COVID-19 evidence in one place on a daily search basis. The search covered a period of time up to July 31, 2020.

Eligibility criteria for selecting studies and methods

We adapted an already published standard protocol for multiple parallel living systematic reviews to this question's specificities. We included randomized trials evaluating the effect of either suspension or indication of angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers as monotherapy, or in combination versus placebo or no treatment in patients with COVID-19. We searched for randomized trials evaluating the effect of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers versus placebo or no treatment in patients with COVID-19. Two reviewers independently screened each study for eligibility, extracted data, and assessed the risk of bias. We pooled the results using meta-analysis and applied the GRADE system to assess the certainty of the evidence for each outcome. We will resubmit results every time the conclusions change or whenever there are substantial updates.

Results

We screened 772 records, but none was considered for eligibility. We identified 55 ongoing studies, including 41 randomized trials evaluating angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers for patients with COVID-19.

Conclusions

We did not find a randomized clinical trial meeting our inclusion criteria, and hence there is no evidence for supporting the role of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in the treatment of patients with COVID-19. A substantial number of ongoing studies would provide valuable evidence to inform researchers and decision-makers in the near future.

PROSPERO registration number

CRD42020182495.

Protocol preprint DOI

10.31219/osf.io/vp9nj.

Macrolides for the treatment of COVID-19: a living, systematic review

Objective

This living, systematic review aims to provide a timely, rigorous, and continuously updated summary of the evidence available on the role of macrolides for treating patients with COVID-19.

Design

A living, systematic review.

Database

We conducted searches in the centralized repository L·OVE (Living OVerview of Evidence). L·OVE is a platform that maps PICO questions to evidence from the Epistemonikos database. In response to the COVID-19 emergency, L·OVE was adapted to expand the range of evidence it covers and customized to group all COVID-19 evidence in one place. Today it is maintained through regular searches in 39 databases.

Methods

We included randomized trials evaluating the effect of macrolides as monotherapy or in combination with other drugs versus placebo or no treatment in patients with COVID-19. Randomized trials evaluating macrolides in infections caused by other coronaviruses, such as MERS-CoV and SARS-CoV, and non-randomized studies in COVID-19 were searched in case we found no direct evidence from randomized trials. Two reviewers independently screened each study for eligibility, extracted data, and assessed the risk of bias. Measures included all-cause mortality; the need for invasive mechanical ventilation; extracorporeal membrane oxygenation, length of hospital stay, respiratory failure, serious adverse events, time to SARS-CoV-2 RT-PCR negativity. We applied the GRADE approach to assess the certainty of the evidence for each outcome. A living, web-based version of this review will be openly available during the COVID-19 pandemic. We will resubmit it every time the conclusions change or whenever there are substantial updates.

Results

The search in the L·OVE platform retrieved 424 references. We considered 260 as potentially eligible and were reviewed in full texts. We included one randomized clinical trial that evaluated the use of azithromycin in combination with hydroxychloroquine compared to hydroxychloroquine alone in hospitalized patients with COVID 19. The estimates for all outcomes evaluated resulted in insufficient power to draw conclusions. The quality of the evidence for the main outcomes was low to very low.

Conclusions

Macrolides in the management of patients with COVID 19 showed no beneficial effects compared to standard of care. The evidence for all outcomes is inconclusive. Larger trials are needed to determine the effects of macrolides on pulmonary and other outcomes in COVID-19 patients.

Systematic review registration

PROSPERO Registration number: CRD42020181032 Protocol preprint DOI: 10.31219/osf.io/rvp59.

Use of Cochrane reviews in nationally-developed clinical practice guidelines in Latin America

Introduction

Cochrane reviews, recognized as the benchmark for high-quality summaries, facilitates healthcare decision-making bringing together all the evidence on an intervention. To date, their inclusion in the Latin American guidelines remains unknown.

Objective

To evaluate the use of Cochrane reviews in nationally-developed clinical practice guidelines in Latin America.

Methods

We conducted a hand search in official government websites and biomedical databases between October 2019 and December 2019, including government-sponsored clinical practice guidelines with recommendations for both the management of health conditions or a healthy lifestyle of the last ten years.

Results

We included 408 clinical practice guidelines from ten countries. We found that 69.8% of them cited Cochrane reviews in their recommendations, and 76.1% of those also used them in their key recommendations. Clinical practice guidelines that did not use Cochrane reviews covered a wide range of topics for which several Cochrane reviews can be found. Countries using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading recommendations were more likely to use Cochrane reviews in a higher percentage of their guidelines (79.4% vs. 61.8%; odds ratio: 2.3; 95% confidence interval: 1.5 to 3.7, p = 0.0001).

Conclusions

Over two-thirds of clinical practice guidelines in Latin America use Cochrane reviews to frame their recommendations. It is necessary to increase the uptake of Cochrane reviews in the region for the development of clinical practice guidelines.

Clinical practice guidelines: Concepts, limitations and challenges

Clinical practice guidelines are the most important documents for the incorporation of scientific evidence in health decision making through the formulation of recommendations. There is a variable terminology used to refer to the documents that guide health professionals in decision making. When clinical practice guidelines are of high quality, they appraise contextual aspects such as the use of resources, applicability, and patients values and preferences. Even so, they are not recipe books, since they may have limitations. In this review, we propose to clarify the different denominations across the various types of documents available to guide the health professional when making clinical decisions. We discuss the main characteristics of clinical practice guidelines, quality assessment, challenges, and limitations.

[Body dysmorphic disorder: clinical aspects, nosological dimensions and controversies with anorexia nervosa]

There is strong evidence about the co-existence of body dysmorphic disorder (BDD) and eating disorders (ED), particularly with anorexia nervosa (AN). An exhaustive review of the specialised literature regarding these disorders was carried out. The results show that their co-occurrence implies a more complex diagnosis and treatment, a more severe clinical symptomatology and a worse prognosis and outcome. Both disorders display common similarities, differences and comorbidities, which allow authors to classify them in different nosological spectra (somatomorphic, anxious, obsessive-compulsive, affective and psychotic). Their crossover involves higher levels of body dissatisfaction and body image distortion, depression, suicidal tendency, personality disorders, substance use/abuse, obsessive-compulsive disorder, social phobia, alexithymia and childhood abuse or neglect background. Treatment including cognitive-behavioral psychotherapy and selective reuptake serotonin inhibitors are effective for both, BDD and ED; nevertheless, plastic surgery could exacerbate BDD. Clinical traits of BDD must be systematically detected in patients suffering from ED and vice versa.

Clinical and experimental study on the long-term effect of dietary gamma-linolenic acid on plasma lipids, platelet aggregation, thromboxane formation, and prostacyclin production

Effects of a dietary intake of the polyunsaturated omega-6 essential fatty acids (EFAs) linoleic and gamma-linolenic acids (GLA) on blood lipids, platelet function, and vascular prostacyclin production were studied 12 hyperlipidemic patients (doses of 3 g/day) and 12 male Wistar rats (doses of 3 mg/kg/day) for 4 months. In humans, GLA supplementation decreased plasma triglyceride (TG) levels by 48% (p < 0.001) and increased HDL-cholesterol concentration by 22% (p < 0.01). Total cholesterol and LDL-cholesterol levels were significantly decreased by omega-6 EFAs. Platelet aggregation induced by low concentrations of adenosine diphosphate (ADP) and epinephrine, and serum thromboxane B2 decreased by 45% both in humans and animals after GLA supplementation. Bleeding time increased 40% (p , 0.01). In rats, vascular prostacyclin production measured by radioimmunoassay of 6-keto-PGF1 alpha was enhanced by GLA intake. These effects of omega-6 EFAs may contribute to cardiovascular protection and prevention of the atherosclerotic disease.

Effect of celiprolol on large and small arteries of the forearm circulation in hypertensive patients

Celiprolol, a new highly cardioselective beta blocker, also has direct vasodilating properties. Since the noninvasive echo Doppler technique applied to the forearm circulation (brachial artery) allows the differentiation of arteriolar vasodilation (revealed by the increasing arterial blood flow velocity) from vasodilation of large arteries (shown by an increase in arterial diameter), it seems important to study the site of celiprolol's vasodilating effect. Thirty-five hypertensive patients, (21 male, 14 female; mean age, 59 +/- 11, range 42-79 years) were treated with increasing doses of celiprolol, 200 and 400 mg, over 15 days. The duplex echo Doppler technique (Aloka 7.5 M Hz probe) was used before and during each celiprolol dose period. Statistical analysis was performed by Student's paired t test. It was observed that celiprolol significantly increases the brachial artery diameter in a dose-dependent manner, and also increases the blood flow velocity (not being direct dose-related). Since the increase in diameter was clear with a higher dose, a dose-dependent increase in blood volume, a decrease in peripheral resistance, and an increase in compliance followed. Since the higher dose of celiprolol did not further reduce blood pressure (BP) in comparison to the lower dose, and a dose-dependent increase in arterial diameter and compliance occurred and a vasodilating effect of celiprolol on arterial wall ensued that was not related to BP. In conclusion, in the doses used, celiprolol dilates both arterioles and large arteries, but the mechanism of action needs to be clarified.

[Hemodynamic effects of hydrochlorothiazide, propranolol and a combination of pindolol and clopamide in patients with essential hypertension]

To characterize the haemodynamic effects of diuretics, betablockers and the association of both, 24 hypertensive patients, stages I-II WHO criteria, were studied. Two haemodynamic studies were performed, before under placebo and after two month of active drug therapy. Seven patients received propranolol (PPL) (160-240 mg/day); 7 patients, hydrochlorothiazide (HCT) (150-100 mg/day), and 10 a combined fixed dose of pindolol (PDL) and clopamide (CLP): PDL 10 mg, CLP 5 mg per tablet, each patient receiving one to three tablets according blood pressure response. The haemodynamic study was performed with percutaneous intravenous flow-directed. Swan-Ganz catheter, associated with direct puncture of femoral artery and measuring cardiac output by thermodilution. Arterial pressure was significantly reduced on PPL (p less than 0.05) and PDL-CLP (p less than 0.01) groups, but not in the HCT group. The cardiac index was reduced by PPL (p less than 0.05) but not by HCT and PDL-CLP. The systemic vascular resistance was only reduced in the PDL-CLP group (p less than 0.05). The use of a betablocker with intrinsic sympathetic activity (ISA) (pindolol) in association with a thiazide diuretic (clopamide) seems to induce a favourable change in systemic resistance without a deleterious change in cardiac output as occurred with propranolol.